Monday, May 30, 2011

Rerun: This Memorial Day

This Memorial Day:

Our men and women are returning from two wars. They have witnessed things and felt things that those of us who stayed home have no clue. Their brains have been overwhelmed, their psychic beings shaken to the core.

This Memorial Day:

Our soldiers may leave the battlefield, but they cannot leave their memories there. Very high percentages are returning home with PTSD, depression, and other mental illnesses. Even those without full-blown symptoms have issues to deal with. Others are ticking time bombs. Suicide will claim more of them than enemy gunfire. Many will attempt to cope by turning to alcohol and drugs.

This Memorial Day:

Many brave men and women have no clue what is about to happen to them. They served as heroes, but, like many who served in Vietnam, may wind up homeless. They may be remembered for their bravery, but we will cross the street to avoid them.

This Memorial Day:

It's not just about flags on graves. It's about serving the people who served our country.

This Memorial Day:

Resolve to do something tangible. Advocate. Donate. Get involved with one of the veteran's organizations. Get involved with a mental health group making an outreach to veterans. Do something. Then keep doing it.

This Memorial Day:

It's our turn now.

Saturday, May 28, 2011

Borderline Personality Disorder - A Diagnosis in Search of Respect

As well as May being Mental Health Awareness Month, May is also Borderline Personality Disorder Awareness Month. Coincidentally, I am in the middle of reworking my one mcmanweb article on borderline into three. Following is some pieced-together extracts from my draft ...

In 2005, I joined the board as an officer in a state DBSA group back east. There, I came across behavior I could not ascribe to bipolar disorder – extremely abusive verbal attacks, explosive meltdowns, public outbursts, poison pen emails, delusional self-centeredness, love and light one minute-on their shit list the next.

Yes, bipolars can behave badly, but this was different. For my own self-preservation, I got out of this toxic environment and cut off all ties with the state organization. I literally wound up hating these individuals and their illness. But I also recognized how lonely life must be for these individuals. None of them was married or in a loving relationship. None of them had children. None of them was employed. All of them engaged in frightening behavior. All were serious accidents waiting to happen.

The illness is called borderline personality disorder. On the surface, the emotional volatility, impulsivity, depressions, mood swings, high drama, and destructive behavior of individuals with this diagnosis resemble bipolar disorder. The suicide rate is in the bipolar ballpark, and the pain and isolation individuals with this illness experience is similar, if not more so.

Yes, the people I encountered may have had bipolar disorder, but something else was going on here, and they were not being treated for it. Their psychiatrists were sending them out into the world with mood stabilizers and false hope. I needed to find out more. The 2006 American Psychiatric Association annual meeting was approaching, and I made it a point attend the few sessions they had on personality disorders.

Is Borderline Real?

Unexpectedly, the first borderline discussion there occurred during question time at a packed luncheon symposium on bipolar II. One of the presenters, Terence Ketter MD of Stanford, happened to say that as opposed to bipolar disorder, which is about MOOD lability (volatility), borderline personality disorder is about EMOTIONAL lability. As soon as they develop an emotion stabilizer (analogous to a mood stabilizer), he said, borderline personality disorder will become an Axis I disorder rather than Axis II.

Axis I disorders, as categorized by the DSM-IV, include bipolar disorder, depression, anxiety, schizophrenia, and other illnesses regarded as biologically-based and treatable with medications. Axis II disorders tend to get a lot less respect. As well as borderline personality disorder, these include antisocial personality disorder, narcissistic personality disorder, and a host of behaviors that impede personal and social function.

During the same round of questions, S Nassir Ghaemi MD, then of Emory University, said that he thought borderline personality disorder was a "clinical condition" rather than a disease. As such, the condition is more appropriate for psychotherapy rather than medications treatment. Hagop Akiskal MD of the University of California, San Diego, was decidedly less accommodating: "I don’t have any use for the borderline diagnosis," he asserted.

Axis II Grind

Joel Paris MD of McGill University is one of the leading authorities on borderline and other personality disorders. In 2006, at the same venue, he spoke to a largely empty hall. The name of his talk said it all: "Personality Disorders: Psychiatry’s Stepchildren Come of Age."

Significantly, Dr Paris was not about to let Dr Akiskal go unanswered. Referring to Dr Akiskal’s long-standing views concerning borderline personality disorder, Dr Paris let it be known, "I would say that is wrong."

In true Axis I depression, Dr Paris explained, when patients come out of a depression, they are nice people again. Individuals with personality disorders, by contrast, can come out of a depression and still have problems with life. Unfortunately, clinicians prefer not to want to hear about personality. It means trouble. They would rather throw more meds at the problem.

The world is complicated, Dr Paris noted, but we want it simple, and therein lies the challenge: In the bipolar II symposium, the presenters were discussing difficult-to-treat depressions. The depressions they were talking about were those that acted suspiciously like bipolar, which strongly implies using mood stabilizers instead of antidepressants.

Dr Paris was also talking about difficult-to-treat depressions, but the ones he described pointed to personality issues and a long course in talking therapy. These patients are not going to get better fast, he warned. Clinicians have to plan for chronicity. Moreover, in a true personality disorder, the course of the illness is different. These individuals are not going to become bipolar over time.

Alas, deep in the heart of psychiatry, Dr Paris was a voice in the wilderness.

Knock Me Over With a Feather

Three years later, I had the Twilight Zone experience of attending a packed session on borderline at the 2009 APA. Earlier John Gunderson of Harvard had spoken to an SRO crowd. The APA program booklet revealed that instead of three or four sessions on personality and personality disorders there were 18, about equal to those on mood disorder (I counted 20). During a break in the proceedings, I turned to the psychiatrist next to me.

What was going on? I asked. Why were things so different this time around? What had changed in the last three years?

More to come ....

Thursday, May 26, 2011

Rerun - Thinking Outside the Box: Lessons From History - The Pax Mongolica

I'm still head down, ass up mucking out the Augean Stables of mcmanweb. In the meantime, this blast from the past from Nov last year ...

I just finished reading Jack Weatherford's "Genghis Khan and the Making of the Modern World." The author, a professor who knows how to write, doesn't exactly present a kinder and gentler Genghis from the one we imagine. But he does make a very strong case that, contrary to popular belief, the net effect of his conquests proved extremely beneficial. Basically, Europe was far too backward to boot up from feudalism to the Renaissance on its own, even with an assist from nearby civilizations.

At the time of his death in 1227, Genghis Khan's holdings extended from the Caspian Sea to the Sea of Japan, embracing virtually all of central Asia, down into China, up into the remote northern steppes. The sheer immensity of his conquests makes Alexander the Great look like a neighborhood bully by way of comparison. Likewise, the Roman Empire and Muslim Caliphate come across as mere subdivisions. Not to be outdone, his successors overran eastern and central Europe, much of the Middle East, and coaxed the rest of China into the fold. In the process, the Empire split into four separate Khanates, but nevertheless kept operating as a fairly cohesive entity.

Historians refer to the 13th and 14th centuries as the "Pax Mongolica." While Europe was contending with war and religious intolerance, Mongolian-ruled Eurasia was enjoying a time of unprecedented peace and prosperity, thanks to the vision of its unlikely founder. Against all odds, young Genghis survived a brutal childhood as part of an outcast family before going on to unite his feuding klansmen into a force to be reckoned with. A brilliant organizer and visionary, he applied the lessons of the remote and inhospitable steppes to managing the world, continuing to learn as he faced new challenges.

The legacy he passed onto his successors included rule of law, secular government, religious toleration, cultural diversity, promotion of learning, free trade, patronage of the arts, the spread of technology, paper currency, appointment by merit, administrative accountability, and much more - one people under one sky.

Suddenly, a seller in China could find a buyer in Europe. Over a now secure Silk Road and new sea routes, goods and ideas flowed in all directions while the standard of living kept improving. The printing press, paper, gunpowder and the compass came west while Arabian science and other advances diffused everywhere. On and on it went, the best of all worlds nurtured by a strange new ruling class unfettered by old conventions.

As Jack Weatherford explains it, "most empires of conquest imposed their own civilizations on the conquered." By contrast, the Mongolians came to the table empty-handed but open-minded. "They did not have to worry about whether their astronomy agreed with the precepts of the Bible, that their standards of writing followed the classical principles taught by the mandarins of China, or that Muslim imams disapproved of their printing and painting."

Likewise, the rulers of the new Mongol Empire had nothing in common with the parasitic aristocracies of the lands they conquered, keepers of the old prejudices. These they killed off wholesale at the slightest pretext.

Of course, nothing lasts forever. Universal ideals were already yielding to the inadequacies of human nature when the largest empire in history was brought down by the humble flea. The bubonic plague broke out in China in the 1330s and spread throughout the rest of the known world on the very trade routes the Mongols had opened up. One-third of China succumbed to the Black Death and anywhere from a quarter to a half of Europe's population met their untimely end.

The plague hit hardest in populated urban centers, literally wiping out the brains of the empire. Commerce and communications ceased. Lands near and far lost touch. The Mongols lost control of their empire and became absorbed into the populations they once ruled. The old order reasserted itself, insular and intolerant, walling the rest of the world out, themselves in.

The Pax Mongolica became a distant memory, but enough after-effects remained to inspire new generations to start thinking outside the box again and shake things up. Ironically, the winds of change blew hardest in backward Europe. History would never be the same ...

Wednesday, May 25, 2011

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

I'm back into mucking out my Augean Stables, otherwise known as updating my mcmanweb site. I have a number of great pieces (at least I think they're great) lined up for this blog, but, in the meantime, from the vaults of "Knowledge is Necessity" (Dec, 2010) ...

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

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

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

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

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

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

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

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

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

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

Here’s where the dimensional component would come in. The draft DSM-5 proposes testing for six “trait domains” that would include:
  1. Negative Emotionality (such as depression or anxiety).
  2. Introversion (such as social withdrawal and intimacy avoidance).
  3. Antagonism (such as callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, and deceitfulness).
  4. Disinhibition (such as impulsivity).
  5. Compulsivity (such as risk aversion).
  6. Schizotypy (involving odd behaviors and cognitions).

These trait domains are based on well-established personality tests such as the five-factor model and Cloninger’s psychobiological model, and would seek answers (note the plural) to such life mysteries as why an individual would abruptly break off a friendship.

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

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

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

Much more to come ...

Sunday, May 22, 2011

When Substance Use Butts Heads with Mood

As you probably know by now, I have been replacing a lot of the old articles on mcmanweb with brand new ones. More recently, my focus has been on disorders that overlap with mood, including schizoaffective and anxiety. This time around, it's alcohol and substance use. Following is an edited extract ...

Walk into any AA or NA meeting, and you will hear people talking about their cravings. Walk into a DBSA group and you will find some of these very same people talking about "self-medicating." Two different problems altogether or two faces of the same problem? It's hard to tell.

Fifty percent of those with lifetime mental illness also have a lifetime history of at least one substance use disorder. Six in ten of those with bipolar have experienced a substance use disorder some time during their life, more than five times the rate of the general population.

Perhaps you can see where I am going with this. If all alcohol and substance abuse is strictly genetic, then why would these genes be so unevenly distributed? Why would they so heavily cluster in the mood disorders population? That can't possibly be right, can it? So what else can be going on?

A Desperate Need for Release?

In the initial going at least, individuals tend to indulge in alcohol and drugs to feel better than they are currently feeling right now. Some may continue this way, but for many the situation has changed. The crying need is for the chemical fix, not the feel-good state (which the brain may have built up a tolerance to).

With a mood disorder (not to mention vulnerability to stress) this is turned around. The overwhelming compulsion is for release from the psychic pain, be it depression or runaway mania or anxiety. A bit of feel-good (or feel less-bad) may be involved, but one is left with the sense of an individual putting out a fire or fleeing a burning building.

But life is complicated. Addicts may claim they are self-medicating. Those who started off self-medicating may not recognize they have have turned into addicts.

Messed Up vs Clear Head

Some over-zealous participants in AA and NA caution that taking psychiatric meds is another form of chemical dependency.

But people take psychiatric meds for entirely different reasons than those talking alcohol or recreational drugs. For the most part, there is no feel-good effect from a psychiatric med. Whereas an addict may start with an initially clear head for the purpose of getting it messed up, a person with a mental illness tends to be coming from the opposite direction.

Of all things, when researchers began investigating the inordinately high rates of cigarette smoking in those with schizophrenia, they discovered that nicotine had the momentary effect of restoring lost cognitive function. Think about it - for the first time in years or decades your brain is suddenly coming in loud and clear. To these individuals, the medically horrendous side effects are well worth the few precious seconds of mental clarity.

If nicotine came in a pill prescribed by doctors, with similar results, would you dare accuse these individuals of having a chemical addiction or dependency? (Nicotine agonists are in development.)

The Craving and Self-Medicating Factors

The inhibitory neurotransmitter GABA quiets down activity in the neuron, which is vital for keeping the brain in healthy stable state (homeostasis). Its tag team partner glutamate achieves a similar end through ramping up neural activity. Inevitably, when things go wrong, the two neurotransmitters are complicit in a range of mental illnesses and conditions, from anxiety to schizophrenia, with depression and mania thrown in for good measure.

When alcohol molecules bind to the neuron's GABA receptors, GABA transmission is increased. Because GABA is active throughout the brain, effects can range from euphoria to sluggish thinking to loss of muscle control. Over time, the neuron structurally changes to accommodate increased GABA supply, setting up the conditions for a craving.

Next neurotransmitter ...

Dopamine is central to pleasure and reward, motivation, alertness, executive function, and muscular control. Dopamine dysregulation (too much or too little) has been implicated in depression, bipolar, ADHD, OCD, aggression, novelty-seeking, schizophrenia, and Parkinson's.

Dopamine surges account for the highs from street drugs such as cocaine and crystal meth and prescription drugs of abuse such as methamphetamines, but these effects tend to wear off as the neuron structurally changes to compensate, again setting up the conditions for a craving.

Then there are brain systems involving serotonin (LSD and ecstasy work on this neurotransmitter), THC (cannabis), and stress regulation.

Since all these systems are intricately interconnected and interdependent, an addiction to one substance may involve an addiction to other substances. Likewise, mental illness and addictions share many of the same pathways. Serotonin has received most of the attention regarding depression, and it is no coincidence that ecstasy provides instant relief. Likewise, for vegetative depressions, a methamphetamine may offer a quick dopamine jump start.

Self-medication, then, is a clumsy and ultimately self-defeating attempt to bring the various brain systems into alignment. Think of alcohol, for instance, as an anti-anxiety med with an outrageous side effects profile. Ultimately, the short-term neurotransmitter surge sets up the conditions for the long-term depletion. Self-medication and craving become one.

Thursday, May 19, 2011

When Anxiety Butts Heads With Mood

I just finished rewriting my old mcmanweb article on anxiety and mood, which I expanded into two articles: Anxiety in Depression and Bipolar, and The Mood and Anxiety Connection. Below are three snippets from the two articles, thoughtfully stitched together for your reading pleasure ...

Emil Kraepelin in his classic 1921 "Manic-Depressive Insanity" had this to say about what he called "excited depression":

It is here a case of patients who display, on the one hand, extraordinary poverty of thought but, on the other hand, great restlessness. ... Mood is anxious, despondent, lachrymose, irritable, occasionally mixed with a certain self-irony. ...

And here he is expounding on "depressive or anxious mania":

A morbid state arises, which is composed of flight of ideas, excitement, and anxiety. The patients are distractible, absent-minded, enter into whatever goes on round them, take themselves up with everything ...

Unbelievably, the DSM-IV is silent on both anxious depression and anxious mania. The DSM-5, due out in 2013, would change this somewhat, with the new diagnosis of "mixed/anxiety depression," but nearly a century after Kraepelin, the people who should know better can't bring themselves to acknowledge the obvious in mania.

Mixed Depression/Anxiety

Filed under "Depressive Disorders" is the proposed DSM-5 diagnosis of "mixed depression/anxiety." This involves "three or four of the symptoms of major depression" (a straight depression diagnosis requires at least five symptoms). One of the symptoms must include depressed mood or loss of pleasure. The depressive symptoms must be accompanied by "anxious distress."

The draft DSM-5 defines anxious distress as "having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen."

In essence, the DSM-5 is part-way to acknowledging that anxiety can be both an illness and a symptom of another illness. Depression, psychosis, sleep, and eating and other conditions already share this dual status. Indeed, in this particular area, the DSM-5 harkens back to the pre-modern DSM-I of 1952 and DSM-II of 1968, which viewed much of mental illness as the result of an underlying emotional disturbance called "neurosis." (More serious was "psychosis.")

According to the DSM-II, "anxiety is the chief characteristic of the neuroses." In a manner of speaking, anxiety both drove neurosis and could be one of its main symptoms, along with depression. Back in those days, symptoms were viewed as maladaptive responses to one's surroundings.

In other words, anxiety and depression and mania and even schizophrenia were seen as failures in our ability to cope. As naive as this may appear today, there is considerable merit in the old view that anxiety is inevitably to be found at the scene of the crime in almost any mental illness, whether as the principal or the accessory. Mix despair with anxiety and we're immobilized, unable to pick up the phone. Change it to a racing mind and we're yelling into that same phone, freaked out over some slight disturbance.

In one sense, the world is way too close and immediate, on the other too far and disconnected. One day we're treading water surrounded by thrashing ravenous crocodiles. The next we're Major Toms, a million miles from nowhere, cut off from humanity.

Mixed Mania/Anxiety

The DSM-IV does not recognize this state, and neither would the DSM-5. From a clinical level, mixed mania/anxiety would probably be impossible to diagnose, so why bother? But on a personal level, we need to acknowledge reality. It's easy, really. Simply imagine a state of irrational worry combined with failure to control one's impulses. Thus, you may find yourself fretting about your situation at work. Fairly normal. What's not normal is storming into the boss' office and quitting your job, with no other job lined up. This happened to me. It wrecked my life, but I'm grateful I ONLY quit my job. In the frame of mind I was in, I could have done something much worse.

An additional twist: Walk into any support group, and you will hear participants discussing their "mood triggers." Excessive worry, for instance, may cause you to lose sleep, which makes you a sitting duck for mania. Or it may set off depression, which later sets up mania. Keep in mind, depression and mania never operate in isolation. We are talking about a constant two-step, in this case with an additional dance partner.

My Driver’s Test Mood-Anxiety Hell

From a blog I did on HealthCentral ...

My anxiety levels are through the roof. I have just met a wonderful woman who lives [40 miles away] in San Diego. I NEED to pass this test. The inspector asks me to turn on my left signal. I turn on my right signal. It's all downhill from there. FAIL! I feel lower than a snake's belly. I'm a loser, an idiot. The woman I just met is going to dump me for sure. We work it out. She will help me. I book another appointment for August.

Two weeks later, I call her in a panic. I have just discovered DMV videos on YouTube. More than a hundred of them. Ten top reasons drivers fail the test. Something about forgetting that Burma is now called Myanmar. Automatic fail.

I’m never going to pass this test!

Yesterday. I’ve willed my heart down to merely 300 beats a minute. Turn left, the inspector instructs.

What did he mean by that? I wonder.

He's scribbling in his clipboard. One turn and already I've given him something to write about! I'm doomed! The test ends. The inspector tells me I have a tendency to overthink and panic. Duh! He tells me I've passed. I passed! I refrain from hugging the inspector.

Wednesday, May 18, 2011

Rerun - Interview: Therese Borchard on the Dark Side of Funny

I often forget what I wrote. So when I happened upon this piece (from Jan 2010) the other night, I read it as if for the first time, as if reading someone else's writing. I enjoyed it so much I decided to share it with you again ...

Therese Borchard has come out with a terrific new memoir of depression, Beyond Blue: Surviving Depression and Anxiety and Making the Most of Bad Genes, that had me rolling in the aisles. That’s right, a book about depression that is funny. I decided to confront Therese on this ...

John: Listen, Therese. William Styron’s memoir of depression was bleak. Sylvia Plath’s The Bell Jar was heart-breaking. Yet, here you are, agony with a thousand punch lines. This has to be sacrilegious.

Therese: Funny you should ask the question that way. Gus Lloyd, who has a radio show on Sirius Satellite, confronted me with the same thing this morning. But he asked me, “How do you know when you are using humor and comedy to heal, and when it is perceived as offensive?” I responded, “I don’t. I guess that’s why a lot of people stay away from humor.” I typically offend 5 to 10 percent of my readers when I use sarcasm and wit in a post. So should I skip the attitude satire? Absolutely not. I hate to say this – it sounds cold and heartless – but I’d rather offend five listeners to allow 95 listeners a moment of healing laughter, than to stay boring and safe. It’s sort of the opposite philosophy of Jesus and the lost sheep. I’d rather lose one sheep in order to help out the 99 that are desperate for a laugh. Sorry, Jesus.

John: Uh, uh. I’m not letting you get away with that. By your own admission, you’re a self-confessed manic-depressive, alcoholic, stage-four people pleaser; ritual performing weirdo, hormonally imbalanced female, and Catholic. What could possibly be funny about that? Honey, you got some ‘splainin’ to do.

Therese: Here’s the deal, John. It goes back to the Seinfeld rule on humor. You remember that episode? When Jerry is telling dentist jokes and his dentist calls him an anti-dentite. And the dentist converts to Judaism so he can tell Jewish jokes safely? If someone came up to me and said, “Therese, you are one manic-depressive, alcoholic, people-pleasing, ritual-performing weirdo!” I would be offended if they A) were wearing ugly clothes, B) could not laugh at themselves too, C) could not check off anything in the DSM-IV, and D) had no sense of humor. I have earned the right to call myself all those things with levity because … for crying out loud … I’ve wanted to die for big chunks my life. Cut me some fricking slack! Now if a former co-worker of mine emails another co-worker and accidentally copies me on the email in which she says I’m looney (true story, actually), then yes, I have a right to be pissed. But can I call myself looney? ABSOLUTELY. I say let’s err on the side of recklessness.

John: Right, that’s your story and you’re sticking to it. Okay, let’s shift gears a bit. Some of our darkest thinkers in history also doubled as our greatest humorists. I’m thinking of Mark Twain, Kurt Vonnegut, and George Carlin. You can also throw in Shakespeare and Swift. What accounts for this? Were they as twisted as you are?

Therese: I believe in the theory of the rubber band. Your brain (sanity) is stretched, and stretched, and stretched, and stretched to where it … ZAP! … just snaps one day, and from that day on, everything in life is somewhat hysterical because you can’t believe how messed up the world is. You see everyone around you trying to walk straight while juggling five heavy suitcases of baggage … and for some reason, it’s funny, and you know you can’t take life so seriously. As G.K. Chesterston once said, “angels can fly because they take themselves lightly.”

Stephen Colbert was interviewed in Parade magazine a while back, and he explained the night to burst out of his shell of pretension and was able to fully be himself on stage. He said, "Something burst that night, and I finally let go of the pretension of not wanting to be a fool." I don’t know, John, something burst in the psych ward, where I sat eating rubber chicken with women wearing granny underwear for everyone to see and painting birdhouses with a teenage boy who wanted to hook up with me at the mall after we were discharged. Some people probably wouldn’t find the humor in it. But man, they do make great social hour stories (and especially since I don’t drink or use any illegal drugs).

John: Are you trying to tell me that had you been born “normal,” you’d be some shallow humorless stuck in the mud?

Therese: Yes. Absolutely. Haven’t you noticed that pattern? Those who’ve had rather uneventful lives don’t have as much to say at cocktail parties as the ones who have been cleaning up feces for a few decades. As much as I curse depression and bipolar disorder (and most of the DSM-IV that I’m diagnosed with … let’s be honest), it has brought me the blessings of humor, perspective, compassion, humility. Plus I write better! Because I no longer have to make stuff up anymore. There actually WAS a guy in my inpatient unit that tried killing himself by chugging down a gallon of Tide laundry detergent. And there WAS a psychotic woman who attacked an innocent 97 year old man one night because she said her spouse slept with the old man’s wife! Let me tell you, that group therapy session was interesting!

John: In all seriousness, Therese, you are a gift to humanity. Any concluding words?

Therese: Thank you, John. As I’ve said to you before, I have no idea how I am going to repay all your kindness and generosity. I think you should rename your blog as “Beyond Blue Promotion Site.” I suppose I must quote Kay Redfield Jamison here, because she gets credit for my philosophy on humor, and I live by her words every day. She says, “Tumultuousness, if coupled to discipline and a cool mind, is not such a bad sort of thing. That unless one wants to live a stunningly boring life, one ought to be on good terms with one’s darker side and one’s darker energies.” I guess I ran from my darker side for so many years. And that just made me more afraid. So now I try to look the beast in the eyes and ask him what he’s got for me, and, whenever possible, to “break his face” as Jerry Seinfeld says, to make him laugh.

Purchase Beyond Blue from Amazon 

Read Therese's blog, Beyond Blue

Tuesday, May 17, 2011

Jung's Red Book! Unbelievable!

Yesterday, UPS dropped off my copy of Jung's "The Red Book." I finally broke down and bought it after a friend emailed me an Amazon gift certificate. These photos (from my iPhone) hardly do the book justice, but do provide an indication of the stupendous treasure I feel I have acquired.

Jung began work on his Red Book in 1913, soon after his acrimonious break with Freud. Jung felt himself slipping into psychosis and feared he was "doing a schizophrenia." Over the next 16 years, he cultivated direct experiences with his unconscious, recording his observations in an exquisitely rendered Gothic script, with beautifully illuminated illustrations.

The manuscript, bound in a red leather cover, sat in a bank vault for decades. Ten or so years ago, Jung's family finally consented to publication, and its release in 2009 created a sensation. The book, printed on museum-quality paper, is larger in area than the average Manhattan apartment.

I will have a lot more to say in future posts. In the meantime, enjoy the pics ...

Sunday, May 15, 2011

Let's Kill the Schizoaffective Diagnosis

Following is a chopped (or should I say slashed?) version of a new article on mcmanweb (with the rather less provocative title of "Schizoaffective Disorder"), which in turn is based on copy-and-paste of extracts from several mcmanweb articles on psychosis and various diagnostic headaches in bipolar ...

Think of schizoaffective as occupying that middle ground where bipolar overlaps with schizophrenia. But what are we dealing with? Schizophrenia lite, BP heavy, a separate illness, two co-occurring illnesses, or something occupying the psychosis spectrum?

The DSM-5, which is scheduled to replace the current DSM-IV in 2013, spells it out: "The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable," but then makes no changes to make the diagnosis reliable.

What We’re Up Against

A number of years back, the International Society for Bipolar Disorders came up with their own recommendations for improving the diagnostic criteria for bipolar. According to their report, genetic studies lend credence to an overlap between bipolar and schizophrenia, with a clustering of both in family groups, and shared suspect genes in both illnesses.

Schizoaffective is thought to occur in less than one percent of the general population (women predominate), but the patient population is much higher owing to clinicians making the diagnosis when they are uncertain.

In schizoaffective, "there must be a mood episode that is concurrent with active-phase symptoms of schizophrenia." This is different than a "mood disorder with psychotic features" or "mood symptoms in schizophrenia." Not that it's easy to tell. Confounding matters is the discomforting reality that schizoaffective is a moving target - the relative proportion of mood to psychotic symptoms may change over the course of the disturbance, not to mention over the long term. Not surprisingly, most patients who receive an initial diagnosis of schizoaffective are later diagnosed with something else.

With all this in mind, the ISBD panel considering the matter recommended eliminating the designation, schizoaffective, in its entirety and substituting it with additional specifiers to schizophrenia, bipolar I, bipolar II, and major depression.

Another Perspective ...

In a research article, psychiatric geneticists Craddock and Owen contend that the current definition of schizoaffective disorder is too narrow to be clinically useful. Instead, it is treated as a glorified "NOS" diagnosis. Compared with the much broader definitions of schizophrenia and mood disorders, "it is inevitable" that the schizoaffective category will seem less reliable to clinicians. This is especially true if clinicians pay little attention to the different ways psychosis presents itself over time.

Despite the lack of respect for schizoaffective, the authors note that "genetic epidemiology supports a strong genetic component to schizoaffective illness." Based on their findings, the authors suggest the concept of "schizoaffective spectrum phenotype" incorporating various shades of mood and psychosis.

What Are We Looking At?

At a 2007 "Deconstructing Psychosis" planning session sponsored by the American Psychiatric Association, the NIMH, and WHO, Carol Tamminga MD of the University of Texas Southwestern Medical Center noted that although mood stabilizers alone can treat psychotic symptoms in acute mania, they are not effective in treating psychosis in schizophrenia. Dr Tamminga offered three possible explanations:

Psychosis has a distinct pathophysiology, common to both schizophrenia and bipolar disorder, and antipsychotics target that molecular mechanism; 2) psychosis is mediated by neural systems which are different in schizophrenia and bipolar disorder, which can be stimulated and treated from multiple points and by many different pharmacologic strategies; and 3) psychosis is a response analogous to "fever" and should not be a primary target for treatment.

Trying to Make Sense of All This

The operative phrase to the DSM-IV schizoaffective diagnosis is:

There is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.

Criterion A lists other symptoms besides psychosis, and calls for a minimum time of one month. (There is a Criterion C for schizophrenia, which mandates a six-month minimum for "continuous signs of the disturbance," but there is no reference to this in the schizoaffective diagnosis.)

Schizoaffective, then, is basically short-form schizophrenia punctuated by relatively brief overlays of depression or mania (the DSM minimum for mania, for instance, is one week). The assumption is that it is highly likely that there will be long periods when the schizophrenia symptoms manifest with no mood symptoms, and indeed this is a DSM requirement.

Thus, schizophrenia symptoms can appear without mood symptoms, but mood symptoms can't appear without schizophrenia symptoms.

Does this sound like schizophrenia to you? Short form or not? Say, schizophrenia with mood symptoms? Is schizoaffective, then, a euphemism diagnosis for clinicians too chicken to tell their patients the truth? It appears that way.

Let's kill the schizoaffective diagnosis, then, and go with the ISBD specifiers approach. Their recommendations:

In schizophrenia, these specifiers::
  1. With symptoms meeting criteria for mania or mixed features.
  2. With symptoms meeting criteria for major depressive disorder.
In bipolar I and II and major depression, these specifiers:
  1. With psychotic symptoms meeting Criterion A for schizophrenia (ie hallucinations or delusions over one month) and for at least two weeks without prominent mood features.
  2. With psychotic symptoms meeting Criterion A for schizophrenia with consistent concurrent mood features.
Meanwhile, Back in the Real World ...

A few questions you need to be asking:

Is your psychiatrist using the diagnosis to bring your clinical condition into sharper relief? In other words, has a competent clinician who really knows you figured out that your bipolar comes with serious complications? And if so, is he or she ready to work with you - including spending extra time with you - in helping you manage?

Or has your psychiatrist basically given up on you? In other words, is your diagnosis a result of the frustration of a lazy clinician who barely knows you and has already written you off as untreatable?

Or is your psychiatrist over-reacting? In other words, is your diagnosis the result of a lazy clinician who barely knows you and assumes that anything that even remotely resembles psychosis must be connected to schizophrenia or schizoaffective? In other words, are you about to be over-treated and over-medicated?

What's in a name? Sometimes nothing. Sometimes everything.

Friday, May 13, 2011

TR and John Muir

Here's an intriguing contrast to my two LBJ pieces this week. I wrote this on our "other" 20th century bipolar President for mcmanweb in 2002. These days, I would have written a much longer piece featuring a lot more of TR's oddball behavior, such as his giving up his day job as a rising political star in the New York legislature and reinventing himself as a cowboy in the Badlands (I kid you not). But this should give you enough to go on ...

"We do not intend our natural resources to be exploited by the few against the interests of the many."

Believe it or not, a Republican President said that, Theodore Roosevelt. TR was not your average President. According to Kay Jamison, who needs no introduction, speaking to a 2002 Johns Hopkins conference, Teddy Roosevelt was "hypomanic on a mild day." He suffered from depression, and mental illness ran in the family, including a brother who had to be institutionalized and a son who committed suicide. He wrote 40 books, and read a book a day, even as President.

The context of Dr Jamison’s talk was exuberance, which was the title of her next book in progress (since published in 2004). We have "given sorrow many words," says Dr Jamison, "but passion for life few." Exuberance, she says, "takes us many places," with "delight its own reward, adventure its own pleasure." But exuberance and joy are also fragile, "bubbles burst, cartwheels abort," all part of the yin and yang of emotion, as "joy with no counterweight has no weight at all."

TR came into the world in 1858 "a full-blown exuberant." According to a Harvard classmate, "he zoomed, he boomed, he bolted wildly." A journalist said that after you went home from a meeting with the President you had to "wring the personality out of your clothes."

In 1903, TR teamed up with fellow exuberant, John Muir, for an extended hiking trip in Yosemite. Nature was Muir’s deliverance from his strict Scottish immigrant upbringing. Someone described his writings as the "journal of a soul on fire." He literally spoke in tongues to wildflowers, and his constant stream of letters to lawmakers ultimately attracted the attention of the twenty-sixth President of the US.

"Any fool could destroy trees," Muir wrote. "They can’t run away." Muir saw God’s immanence everywhere in nature, particularly in the mighty sequoias. "Unfortunately, "God cannot save trees from fools," he observed. "Only the government can do that."

TR was a committed conservationist long before he met John Muir, but after the Yosemite trip he marshaled his exuberance with new urgency. When TR assumed office in 1901, half of the nation’s timberlands had been cut down, the buffalo and other species faced extinction, and special interests were teaming up to lay waste to huge tracts of pristine wilderness.

Thanks to TR, five national parks were created, along with 150 national forests, 51 bird refuges, four national game preserves, 18 national monuments (including the Grand Canyon which later became a national park), 24 reclamation projects, and the National Forest Service. Significantly, TR extended the concept of democracy to include future citizens, arguing that it was undemocratic to exploit the nation’s resources for present profit. "The greatest good for the greatest number," he wrote, "applies to the number within the womb of time."

In 1912, a would-be assassin shot TR in the chest. Faced with the prospect of premature death, he remarked, "No man has had a happier life than I have led; a happier life in every way."

The deaths of his first wife and mother on the same day followed by a grieving period that lasted two years seemingly belies that statement, but personal realization has long been recognized as the reconciliation of opposites, and the same applies to John Muir, as well, who wrote he only went out for a walk but stayed out till sunset, for "going out was coming in."

Was LBJ Bipolar? The Case For ...

Blogspot lost my second post on LBJ, from Wed. Here it is ...

Yesterday, I made an unassailable case for the fact that LBJ, the 36th President of the US, did not have bipolar. Okay, let’s assail it.

Bipolar is as much defined, if not more so, by its context as its symptoms. Call it the Zen koan disease: If a crazy person is leading a fully productive and enviable life, does he have a mental illness?

Of course not.

Yes, LBJ had a lot of characteristics you could describe as bipolar, but at age 58, in 1966, he was indubitably the most successful man in the world. He assumed the Presidency in 1963 following the assassination of JFK, then was elected in his own right in 1964 by what was then the widest margin in history. Two years later, with a string of Great Society initiatives, he was on the cusp of being regarded as the greatest President ever.

His entire public life prior to that was three unbroken decades of stellar achievement. His talent and drive would have made him most-likely-to-succeed in any situation, but LBJ was also the beneficiary of extraordinary good luck. At certain critical points in his career, key opportunities would open up - a Congressional or Senate seat becoming vacant, a leadership position in the Senate ...

His lucky streak continued into his Presidency. Change was in the air, and the public willingly placed its faith in their new President, who was uniquely qualified to get things done. Johnson knew he had a rare window opportunity that would close fast, and he acted without hesitation.

The Great Society was a calculated risk. A major tax cut - which pleased the business community no end - stoked the economy, which in turn filled government coffers. As long as prosperity increased, no one was about to question how the wealth was distributed.

But raised hopes also ignited pent-up frustrations. A six-day race riot in Watts LA in the summer of ’65 signaled that racial divisions ran far deeper than people ever imagined. As African-Americans became more assertive, white backlash deepened. The “Solid South,” which had faithfully voted Democratic, was shifting to the Republican side.

Meanwhile, baby boomers, who had grown up in far different circumstances than their parents, were now beginning to assert themselves. By any standard, LBJ was by far the most progressive President in history, but an increasingly vocal population on the other side of “the generation gap” viewed him as a relic.

Nevertheless, the situation was manageable. A booming economy and a successful Great Society overseen by an attentive President would see America through its crisis of identity.

That’s when LBJ’s luck ran out.

In 1965, LBJ decided to increase troop levels in Vietnam from 75,000 (mostly in a limited role) to more than 200,000 (as full-scale combatants). His strategy was based on the misplaced notion that the North Vietnamese leader, Ho Chi Minh, in the face of overwhelming US military might, would come to his senses and seek a peaceful settlement. He didn’t.

By 1966, Johnson’s position was untenable. The one thing that hawks and doves could both agree upon was there was no end in sight to this war. Doris Kearns Goodwin’s 1976 “Lyndon Johnson and the American Dream” at this stage portrays an increasingly irrational President for the first time in his life at a total loss.

Johnson’s War had a zillion fall-out effects. Among them, it overheated the economy and kick-started inflation, which would hobble economic growth for decades to come. It also drained vital financial resources from the Great Society, as well as diverting crucial executive oversight, virtually killing the infant in its crib. This set the scene for disenchantment over “big government” programs and the right-wing counter-revolution to follow.

Finally, resentment over Vietnam brought all of society’s underlying divisions to the surface. The nation may not have been in anarchy, but to a casual observer of the TV news in 1967 and 1968 it certainly seemed that way.

As the situation grew increasingly worse, LBJ retreated into his shell, taking advice from only a small cadre of trusted and sycophantic advisers. Instead of making the necessary  course corrections, he only justified his disastrous decision-making. At this stage, in the last year of his Presidency, Goodwin gives us the impression of a country being run by a mad man. She uses the terms “obsessional” and “delusional” to describe his thinking:

In the past, Johnson had displayed a fine sense of discrimination about his political opponents, recognizing his enemies today might be his allies tomorrow. Now he became unrestrained and reckless, creating a fantasy world of heroes and villains. Members of the White House staff who had listened to the violent name-calling were frightened by what seemed to them signs of paranoia.

She continues:

Suddenly, in the middle of a conversation, the President’s voice would become intense and low-keyed. He would laugh inappropriately and his thoughts would assume a random, almost incoherent quality as he began to spin a web of accusations.

On March 31, 1968 - virtually unable to govern and with his popular support eroding by the day - Johnson announced that “I will not seek, nor will I accept, the nomination of my party for another term as your President.”

LBJ left office at the beginning of 1969, never to return to public life. He died Jan, 22 1973, an embittered and broken man, two days following Nixon’s inauguration to a second term, one day after the announcement of a Vietnam cease-fire and the announcement of a Nixon plan to dismantle the Great Society.

So there you have it, the bipolar Zen koan revisited. A man who lost his mind, his job, public affection, and his legacy. Would it be fair to describe this man as living with bipolar? You tell me ...

Wednesday, May 11, 2011

Was LBJ Bipolar? The Case Against ...

Did Lyndon Baines Johnson live with bipolar disorder? His accomplishments clearly illustrate he was no ordinary man while his failures point to a tragic figure out of touch and out of control. The diagnosis has been loosely bandied about in relation to the 36th President of the US. But is it accurate?

Doris Kearns Goodwin in her 1976 “Lyndon Johnson and the American Dream” offers some excellent insights. Goodwin had a ringside seat into LBJ’s descent into his dark side when she joined his staff in 1968 in the waning months of his Administration. LBJ took a fatherly interest in his young intern, and she became his confidante and student, a relationship that continued into his retirement in 1969 to his death in 1973.

The B-word is not mentioned in Dr Goodwin’s account (it would have been the MD-word back then), nor does she even suggest that LBJ had any diagnosable condition. But she does make ample reference to his legendary mood swings, unquenchable drive, over-bearing nature, and times of despair.

Bipolar, along with any mental illness, is a hindsight diagnosis, only applied after things have gone horribly wrong, never in anticipation thereof. Walk into any DBSA support group and you will hear accounts of busted lives, careers derailed, relationships gone sour, intense psychic pain. While Abe Lincoln could have easily pulled up a chair and made himself at home (as one with depression, not bipolar), LBJ would have been out the door in nothing flat.

Bipolar? We are talking about a man with an unbroken career arc that began as a congressional aide in 1931 and culminated in his ascent to the Presidency in 1963. In between, he served in the House, the Senate (where he reshaped the institution as Majority Leader), and Vice-President. Along the way, there was nary a hiccup to his career, no crisis of faith, no time in the wilderness, no gap in his resume. On top of that, his marriage to Lady Bird held rock steady.

Sound like the kind of person you would run into at a support group? I didn’t think so. Yet, as Goodwin is quick to point out, behind the mask of success was a man with many insecurities, sometimes barely able to hold it together. At one point, in a deep funk, he instructed an aide to alert the press that he was dropping out of his race for the Senate. The aide, in consultation with Lady Bird, ignored the request.

Johnson was in his element when he was in control, whether as a college student seizing the moment or as a young politician on the make or as a wheeling-dealing Senator who was arguably the most powerful man in Washington outside of Ike. Then he made the seemingly disastrous career move of serving as JFK’s Vice President. Even though he was given numerous important responsibilities, it was Kennedy’s show, not his.

Dr Goodwin gives us the impression of a man dutifully showing up for work, loyal to his boss, but not engaged, almost in a stupor. Had JFK served out his full term in office, with the strong probability of another, LBJ may well have had his time in the wilderness, but an assassin’s bullet changed everything.

What follows is the stuff of legend. A reanimated LBJ, with a singular sense of purpose, led a bereaved nation through crisis and on a mission to complete what his martyred predecessor had started. Then he initiated the most ambitious effort ever to reshape the face of the nation with his Great Society programs. Civil rights, voting rights, housing rights, Medicare - the scope of his achievements was unprecedented. Education, the war on poverty, model cities, clean air, clean water - there was no end in sight.

Alas! All of us who lived through the sixties know the tragic ending to this story. Many attribute Johnson’s decision to expand US military involvement in Vietnam to an act of madness, but, as Goodwin points out, Johnson’s key advisers from the Kennedy Administration were thinking the same way.

The policy may have been mad, but it was a rational act conducted by rational men, very much in character with how America did business. But Goodwin points to some complicating elements. The key one was that it was impossible to run both the Great Society and an overseas war at the same time. Johnson went ahead with both anyway.

Something had to give. Major understatement.

More to come ...

Monday, May 9, 2011

Gina Pera: Mental Health Hero

In a recent post, A Dying Breed, I observed that:

A lot of what passes for academic psychiatry these days is performed by researchers who don’t even see patients. This explains why the DSM symptom lists are so spectacularly out of touch with clinical reality. This explains why the people putting together the new edition of the DSM don’t even deign to listen to Akiskal and Goodwin.

It also explains the pathological arrogance of psychiatric thought leaders such as Andrew Nierenberg of Harvard who assume their MD somehow trumps the facts. (Recently, Nierenberg presumed to “refute” and “repudiate” Robert Whitaker, author of “Anatomy of an Epidemic,” but wound up delivering very sick personal insults instead.)

Don’t these guys ever get out in the real world? I could only wonder.

But sicko also works the other way. There’s a lot not to like about psychiatry, but the conversation is frequently derailed by a vocal antipsychiatry fringe who at once romanticize mental illness and deny it exists. In my observations, a lot of individuals with unresolved personal issues are drawn into the movement.

But, as my friend Gina Pera pointed out to me sometime back, antipsychiatry also attracts a group of detached intellectuals, some with solid credentials. Here is an extract of her one-star review of Christopher Lane’s 2008 “Shyness: How Normal Behavior Became a Sickness”:

I'm bone weary of non-psychiatric (perhaps even anti-science) experts opining on subjects they view from afar, as intellectual abstractions - and apparently with little compassion based on how their ideas play out in the real world. These books might better be confined to academia's stage of ideas and not presented to the public with any kind of meaningful authority.

I haven’t read Lane’s book, but I do have deep personal experience with “shyness,” which I can assure you cannot be written off as “normal.” Coincidentally, within a day or two that I became aware of Lane’s book, I heard author Vivian Eisenecher talk about her personal experience with social anxiety. Thanks to Paxil, she related, she was able to participate in AA meetings, which led to her winning her life back.

So much for the likes of Christopher Lane, who is a professor of literature and clearly has not been exposed to the realities of my world or yours. The clencher was when, on his Psychology Today blog, he cited former antipsychiatrist blogger Phillip Dawdy as authority for the proposition that “the bipolar child is purely an American phenomenon.”


I once made the mistake of actually assuming I could reason with the likes of Dawdy and challenged him to actually talk to the parents of kids with a bipolar diagnosis. Dawdy did not take up the challenge. It was far more convenient, instead, for him to continue to exclusively interview his keyboard and brand me as an enemy of the people.

My friend Gina Pera is no stranger to personal abuse from antipsychiatry nutjobs. Gina is the author of the very informative 2008 book, “Is It You, Me, or Adult ADD?” Her blog, The ADHD Roller Coaster, is required reading. Her husband has the illness, and Gina gets out in the real world, actually listening to people and advocating for recognition and treatment of the illness. In the course of her work, Gina does not hesitate in calling out the ill-informed for the frauds that they are.

Gina’s latest close encounter came when she was listening to “The Cambridge Forum” on her local NPR station. The show featured “leading neuroscientist” Steven Rose, author of several books and 300 research papers who is affiliated with a number of universities. On his website, Rose describes himself as having “been actively concerned with the ethical, legal and social implications of developments in science, especially in the fields of genetics and neuroscience.”

So far, so good. But on the show that Gina heard (which I did not), Rose started pontificating about mental illness and apparently started saying stupid things. This was too much for Gina, who posted:

Rose is way out of his depth, coming from a country (UK) that is only now beginning to recognize and fully address ADHD, much to its citizens' detriment. He pulls out all the old myths - that Ritalin is for controlling misbehaving little boys, that ADHD is a big pharma conspiracy, blah blah blah. This is an "expert"?  If nothing else, any "expert" who talks about Ritalin as the medication of choice betrays their ignorance of ADHD.

She goes on to say:

By giving Rose this platform, you are helping to reverse the progress achieved by much smarter (and more compassionate) neuroscientists who have dragged this country kicking and screaming into the 21st Century when it comes to understanding complex issues such as ADHD. In so doing, they have set a model for the rest of the world. And indeed, our experts are the envy of the world. Perhaps Rose's marginalized ego has been tweaked, so he must turn it around - that is, the US has it all wrong.

Okay, Gina. Tell us what you really think:

You have showcased a luddite, marginal crank who obviously needs a career boost. The man's pomposity and sheer disregard for the facts makes me ill.

The common thread in all of this, of course, is people who fall in love with their own ideas, be they psychiatry thought leaders, antipsychiatrists, or “experts” mindlessly spouting someone else's party line. The only cure, of course, is getting out in the real world and actually listening to people. Is that asking too much? Yes, apparently.

Many thanks, Gina, for the reminder. It takes a lot of guts doing what you do. Hero status to you.

Saturday, May 7, 2011

The Vital Importance of Listening

Following is one of two new articles on listening I uploaded to mcmanweb. These articles had their origin in pieces I did for BipolarConnect a few years ago. Enjoy ...

You are seated at a job interview. Or you may be one-on-one at a social gathering. A lot may be riding on the next few minutes or very little. Either way, a successful outcome will enhance your sense of connectedness and move your recovery forward. You have already figured out that yammering in a loud voice only works if you are employed by Fox News. Thankfully, your meds will keep that from happening.

But what if you fail to grasp the significance of your prospective employer glancing at his watch? Or a potential new friend clearing her throat? There is no pill for that.

Poor Bob. How can I ever forget? I ran into him at open mic night at a NAMI convention a number of years back. He had considerable keyboard talent, and he let it be known to me he also plays four saxophones.

For the uninitiated, if you play one sax you play them all, plus all manner of reed instruments. No one except maybe Forest Gump says, "I play four saxophones." Fortunately, Bob was in a safe place. I replied by asking who his favorite sax players were.

On the last evening of the convention, a fifties-sixties cover band was setting up. I was talking to the sax player. Out of the corner of my eye, I spotted Bob with his parents. Without warning, without waiting for a pause in our conversation, Bob broke formation, approached the sax player and, without introducing himself, blurted out:

"I play four saxophones."

The sax player and I looked at each other. Oh-oh, I thought. This is the real world now. The sax player, of course, had nothing to say. Whatever reaction Bob had been expecting or hoping for wasn't going to happen. There was nothing left for him to do but rejoin his parents and move on.

Imagine how the conversation (and his night) might have gone had Bob waited for an appropriate break and opened with, "Say, is that a Selmer Mach VI you're packing?"

A year or two later, I was talking to a mom with a 14-year-old daughter. The mom related to me how her daughter - let's call her Patty - had approached her in a state of confusion, seeking motherly counsel. Apparently, Patty had told a friend that she didn't like the bangs on her hair. The friend got all upset. Patty was taken aback by her friend's reaction. She thought it was honest feedback. She meant no harm.

Patty and her friend are learning to grow up, though over the course of the next several years it will appear as if both are regressing to age two. Every day, Patty and her friend will be challenged by new situations. As their brains store new memories and build complex neural networks, the two will respond to similar events far more skillfully, with the confidence to navigate novel ones. They will enter adulthood and the workforce socially adept, and will continue to improve.

Poor Bob. I'm guessing he has been sheltered from the real world for a good deal of his life. But even a short break from life's rumble and tumble has the potential to incapacitate us for a lifetime. Alas, Bob and I have a lot in common.

Clawing my way back from my illness - that was relatively easy. Breaking out of my isolation - essentially learning to reconnect - that was hard. Fortunately (I think), I had a lot more going for me than Bob. I had been trained as a lawyer and been successful as a journalist. At least, in the art of communication, I had achieved a certain level of proficiency.

Active Listening

At the same NAMI convention, I had breakfast with highly regarded author and journalist Pete Earley. Later in the day, NAMI would honor him for his outstanding book, "Crazy: A Father's Search through America's Mental Health Madness."

In the course of our breakfast, Pete demonstrated why he is a way better journalist than I am. It was simple. He got me to do just about all the talking. Journalists make their living by getting the other person to talk. Since this is a skill that carries over extremely well into social settings, let's examine a few of the things Pete did:

First, he made ME feel like the star attraction, not him. He showed he was glad to see me, he made me comfortable. He complimented me on my book. He acknowledged my journalistic strong suits and showed he was interested in picking my brains on a topic that was my passion (brain science).

Out of compassion, I kept my answers short, giving Pete plenty of opportunity to break in and change to a subject more to his liking. Instead, he fed my talking points back to me, in his own words, showing he was both listening and interested. Soon I was singing like the Mormon Tabernacle choir.

Naturally, I came away from our "conversation" thinking Pete Earley was the greatest guy in the world, which, of course, he is.

Pete was the "active listener" in our conversation. My first real experience with active listening occurred one year out of law school when I improbably landed a senior editorial position as a financial journalist. I knew nothing about finance. I knew nothing about journalism. Moreover, I was a slow study.

One of my first assignments was to interview a prominent tax accountant. We settled into his well-appointed office, with a spectacular view of the harbor. I pulled out my notebook. It was time to pretend I was a journalist.

The success or failure of my interview, I knew, was riding on my ability to listen. In essence, to respond to my subject's remarks in a way that would move the conversation forward. Thus, if my interviewee were to say something like, "Tax policy needs to be based on fairness and equity," I needed to reply with something like: "Do you think the tax laws are fair right now?"

We weren't too far into the conversation when I predictably became totally lost and confused. Words and phrases such as "amortization" and "zero-based budgeting" have a way of doing that to you.

Fortunately, I was the beneficiary of beginner's luck. "Let me see if I got this right," I recalled interjecting. Then I attempted to restate my subject's point, but in my own words.

Apparently, restating - reframing, interpreting, reflecting - is a cardinal principle of active listening. The interviewer benefits from getting the facts right. The interviewee benefits from the reassurance that he or she is not talking to a brick wall. Those in the "people professions" engage in this sort of thing all the time.

In these situations, you need to bury your ego to the point where YOU don't exist. Again, I was the beneficiary of beginner's luck. Since I knew nothing about taxation, I had no temptation to jump in and show off how much I knew.

Unfortunately, that was not the case in my personal life. At the same time, my first marriage was falling apart. Neither of us were listening. Both of us were doing a lot of shouting. Sad to say, we tend to be so busy thinking about what we want to say next that we fail to pay attention. We only want to talk. We fail to realize that talking doesn't work if no one is listening.

Within months, I was out of the house, never to return. The job that I knew nothing about? Turned out that after three years, I left on my own terms for an even better position in the same field. I actually wound up publishing three books on business/finance topics. Of all things, by learning to listen, people actually wound up wanting to hear me talk.

Crazy world we live in.

Other listening article ...

Thursday, May 5, 2011

LBJ, Senatorial Statesman

A year ago, I visited the Eisenhower Presidential Library in Abilene. As I reported in a piece I did soon after:

Eisenhower was a unifier, a consensus-builder. A Republican, he viewed Democrats as collaborators rather than political enemies. This was a skill he acquired as Supreme Commander of the allied armies during World War II, where dealing with the likes of de Gaulle and Montgomery often proved far more problematic than fighting Rommel’s Germans.

Fortunately, Ike served in an era of consensus-builders - political statesmen who put the public good above their own partisan interests. In today's political and media climate, he might have trouble finding a single political partner to collaborate with. Instead, with a little help from his friends (including Democratic Senate Majority Leader LBJ), he presided over a decade that people now look back upon (often erroneously) with a sense of nostalgia.

The book I happen to be reading right now is Doris Kearns Goodwin’s 1976 “Lyndon Johnson and the American Dream.” In Chapter Five, “The Senate Leader,” (the pic is from his Senate days) Goodwin reports:

“With few rare exceptions,” Johnson contended, “the great political leaders of our country have been men of reconciliation - men who could hold their parties together. Lincoln never permitted the radical Republicans to drive more moderate elements out of the party. .... A true leader is a man who can get people to work on the points on which they agree and who can persuade others that when they disagree there are peaceful methods to settle their differences.”

The liberals within his own party attacked LBJ for being entirely too accommodating of Ike. LBJ’s answer was that “a party that is overly partisan, overly quarrelsome and obsessed solely with politics will lose.”

Thanks in large part to Johnson, Ike was able to enjoy a highly successful Presidency, leaving office as one of the most beloved US leaders of all time. But the 1960 Presidential election vindicated LBJ when voters elected a Democrat as his successor.

As the President who assumed office following the assassination of JFK, Johnson carried out what his predecessor had started and appeared on the verge of the type of greatness we reserve for the likes of FDR. Ultimately, his personal failings would bring him down, and he left office a broken man, with a deeply fragmented nation he never possibly could have imagined.

I recall a Time cover story from the era portraying a beleaguered LBJ as Lear, having lost control of his once-happy and loyal political family. The Democratic party could not save itself from its own partisan in-fighting. The ironic benefactor turned out to be the consummate partisan Richard Nixon, the loser in 1960.

LBJ’s failures as President continue to haunt us, but his service as both Senate Minority and Majority leader stands supreme as one of the great displays of statesmanship ever. Give Ike equal credit, too. Both men put country way ahead of party or ideology. Johnson may have been the leader of the loyal opposition, but the emphasis was on loyal, not opposition, certainly not oppositionally defiant.

Tuesday, May 3, 2011

The $175,000 Question: Do Psychiatrists Earn Their Keep?

According to an April 28 Medscape survey of 15,000 US physicians across 22 specialties, psychiatrists earned $175,000 in 2010, one of the lowest-paying fields in medicine, little better than pediatricians at the bottom and half as much as top-earning orthopedic surgeons at $350,000. Only about two percent of psychiatrists earned $500,000 or more, in contrast to more than 20 percent of their counterparts in orthopedics.

Lest you think psychiatrists are getting a raw deal, reports that the median yearly income for a PhD psychologist is $82,000. Meanwhile, reports the yearly salary range of an MSW psychotherapist at $44,000-$65,000. Maybe this is why more psychiatrists than orthopedic surgeons in the Medscape survey reported feeling their compensation was fair (58 percent vs 47 percent).

According to the Medscape survey, most psychiatrists see patients less than 40 hours a week (with a quarter putting in at least 15 hours a week on paper work), but patient loads of 50-75 visits a week are not uncommon, especially for psychopharmacologists. About half reported seeing patients for 25 minutes or longer. The rest saw patients for less than that.

Do psychiatrists really spend that much time with patients? A NY Times article (reported on this blog) from early March, citing the case of one beleaguered psychiatrist, gives a far different impression:

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. ... Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

But Medscape sees a dangerous trend, as well. Citing Nassir Ghaemi, MD of Tufts University:

This kind of setup ensures that drugs will be given for symptoms, which is all one can do with quick appointments, as opposed to using drugs to treat diseases, not symptoms, as I recommend and as is part of the Hippocratic tradition. Identifying diseases that underlie symptoms requires longer and more careful evaluations than I fear the average psychiatrist gives the average patient.

Which leads to the $64,000 - no, make it $175,000 - question: Never mind their education and training and the work they put in - in terms of the actual service they provide and the results they achieve, do psychiatrists actually earn their keep?

You tell me ... 

The "Truth" About Finding Bin Laden

Sometimes I’m so prescient I have to kick myself. No doubt, you are all thinking the same thing. As you recall from my review of the movie version of Ayn Rand’s “Atlas Shrugged” a week ago:

I’m sure the military right now is playing this movie to suspect terrorists at Gitmo to get them to confess. Where water-boarding failed, this horrible excuse for a movie may well succeed. In the name of humanity, we need to find a more humane form of torture.

I’m not going to speculate on whether my review planted the seed. We’ll stick to the facts: According to information I am making up as I am going along, five minutes into the most crapitudinally piece of shit movie of all time, the Gitmo prisoners en masse spit up the location of Bin Laden. I am told they sang like the Mormon Tabernacle Choir.

Think about it. Ten years - nothing. What was different this time? I rest my case. I’m using the same Fox News disregard for facts and reason, so the infallibility of my conclusion is beyond reproach.

Of course, the same people demanding Obama’s birth certificate are now demanding Osama’s death certificate. Oy! You just can’t win with these nut jobs.


I have never wished anyone dead, but I have read some obituaries with great pleasure. - Mark Twain

To the families of the 9/11 victims, a moment of observance. To the men and woman who serve, my heartfelt gratitude.