Tuesday, January 31, 2012

Robert Whitaker: Dangerous in America

On his Mad in America blog, in a Jan 12 post Rethinking Brain Research in Psychiatry, Robert Whitaker, author of "Anatomy of an Epidemic," made the very legitimate point that brain studies on those with mental illness fail to account for the effects of exposure to psychiatric drugs.

Agreed. So, if you slice and dice the brains of deceased individuals with schizophrenia and bipolar and compare them to “healthy” brains, as scientists at the Scripps Institute very recently did, and find that DNA “stays too tightly wound” in the brain cells of schizophrenia subjects, is the effect attributable to the illness, as the researchers suggested, or to the meds the patients have been on all these years, as Whitaker argues needs to be controlled for?

Furthermore: If we can’t say for sure, is the study actually worth the paper it’s printed on? No to everything, says Whitaker most emphatically. “First, let’s look at this particular study,” says Whitaker, who then does not look at this particular study. What Whitaker fails to mention is the study’s real finding and its implications: that a certain gene regulation process observed in neurological disorders also has a correlation to schizophrenia.

The study, published in Translational Psychiatry, sheds very important light on the developing field of epigenetics, which is rewriting the entire book on genetics. If you haven’t heard of epigenetics, don’t worry - you will. I first reported on the topic back in 2004, when a PubMed search listed but one author researching bipolar from an epigenetic perspective. Now epigenetics is emerging as the main event. Last year, I heard Jonathan Sebat of UCSD talk about “copy number variants” in schizophrenia and autism.

Back to the study: The devastating effects of the acetylation of histones (which appears to drive the “tightly wound” DNA dynamic) is the narrow story. The insights the study sheds into the dynamics of epigenetics is the wider story. Both together add up to the real story. Here is the scientific gobbledygook from the research article:

The major findings from this study are: (1) histone ac-H3K9K14 levels are correlated with gene expression levels for several schizophrenia-related genes, including GAD1; (2) age is strongly negatively associated with promoter-associated histone acetylation levels in normal subjects and those with bipolar disorder, but not schizophrenia and (3) histone H3K9K14 levels are hypoacetylated at the promoter regions of important genes in young subjects with schizophrenia.

Maybe another group of scientists will discover that psychiatric meds are involved in the histone acetylation process, but a further study would require funding, and here Whitaker has his own agenda.

Whitaker says the researchers at Scripps could have “administered neuroleptics to healthy rats.” Huh? This was an epigenetics study, not a drug company pre-clinical trial. Does Whitaker even know the difference? Has Whitaker even heard of epigenetics?

“This is why I think it is time for the NIMH to reallocate its research dollars,” says Whitaker. “Decades of such brain research has not produced any notable therapeutic payoff.”

And it is an absolute certainty that there will be no payoff if propagandists such as Whitaker have their way. For there to be any kind of therapeutic pay-off, first we need to find out what is really going on in the brain. NIMH research has led the way in busting old myths (ironically, Whitaker relies on this research in Anatomy of an Epidemic) and has totally changed how we think about brain function and mental illness.

But it also reveals how little we truly know. Alas, there are no easy answers. All the low-hanging therapeutic fruit has already been plucked. Research is badly underfunded, especially with no short-term pay-offs in sight. Today's research efforts are for the benefit of future generations. That's what civilization is all about. We work, we sacrifice, for those who come after us. But there are no guarantees in the frustrating and noble quest for knowledge.

Sunday, January 29, 2012

Rerun: Mahler: The Man Who Saw It Coming

I just got in the door from a weekend trip to LA. There, I experienced the ultimate musical performance of my life - Dudamel conducting Mahler Symphony 6. The following is from a mcmanweb article I wrote in 2004, which I posted in edited form as a blog in June 2011. Enjoy ...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bernstein conducting the opening to Mahler's Fifth

Wednesday, January 25, 2012

The Book of Fort: The Two Wise Old Fools

Book II in the series ...

At the watering hole, along the barrens of Fey, on the fork of the road leading to Mem in one direction and Ar in the other, the wise and righteous Fort encountered a weary stranger in threadbare garments. And although Fort would later go hungry, he offered the stranger his last loaf, which the man eagerly consumed.

Fort bid the stranger to make himself comfortable, then asked his name.

“They used to call me Saul,” the stranger replied in a defeated voice.

“And what do they call you now?” inquired Fort. “It hardly matters,” the man replied. “Just call me Saul.”

Whereupon Saul related an account when, as a much younger man, God had appeared to him in a vision, and thus filled with this vision he had traveled far and wide, enduring many privations, braving persecution and hardship, to spread the good news.

"Five times, in the hands of my own people,” he related, “I have received the 40 lashes minus one. Thrice was I beaten with rods. Once was I stoned, thrice I suffered shipwreck, a night and a day I have been in the deep. Angry mobs, robbers, betrayal from my brothers, in toil and hardship, through many a sleepless night.”

“Indeed, you have endured much,” said Fort, “and your undertaking has been very noble.”

But Saul only shook his head in resignation. “I was young, I was foolish,” he reflected. “I thought I could change the world.”

“And now?” Fort inquired.

“I am old and wise,” Saul replied. “No one listens.”

“Indeed, you are very wise,” Fort replied.

“Wise enough to know the follies of my ways,” said Saul.

“But surely,” protested Fort. “There is great merit in service to God.”

“And how does God repay me?” Saul replied. “By sinking my boat.”

“Indeed,” allowed Fort, “God is hardly worthy of your service. But your people, your followers, surely they possess far greater wisdom. Surely, their numbers are legion.”

Saul laughed bitterly. Casting one arm over the empty expanse of the barrens, he observed, “Ah, the multitudes. As you can see, I never get a moment to myself.”

“But you are far from home,” protested Fort. “Surely, upon your return, by a warm hearth, you will be welcomed with open arms.”

Saul made a sad face.

“I understand,” said Fort. “Had only your own people proved worthy, it would have been easy to forgive God. But perhaps neither God nor your own people are to blame. Perhaps it is your message that is unworthy.”

Saul’s aspect appeared questioning.

“A worthy message,” explained Fort, “would have attracted people of high status and considerable means. You would be supping with kings. You would be resting your head upon fine cushions. Heralds would be proclaiming your wisdom far and wide. Alas, if only your message were worthy.”

“Alas,” acknowledged Saul, “my message fell on deaf ears. Only people of no account listened.”

“People of no account,” repeated Fort.

“People of modest means,” explained Saul, “barely able to eke out a living. Not to mention people of no means and wretched status, outcasts, slaves, women, lots of women.”

“The wrong people,” Fort concurred. “People of no use to you. Clearly, what have they done for you?”

A flash of anger appeared in Saul’s eyes. “They took me in,” he exclaimed in a voice robust with indignation. “They provided for me with what little they had. They journeyed with me. They shared my hardships with me. They risked their lives for me.”

Fort affected to reflect upon the matter. “Ah,” he said at last.

“Gladly,” said Saul, “for these people, I would have God sink my boat - again and again.”

“Ah,” said Fort.

And the realization dawned in Saul’s eyes. Tears flowed down his cheeks, his carriage trembled. “I am greatly indebted to you,” said Saul to Fort. “You are indeed a very wise man.”

“A wise old fool,” Fort corrected in a kindly voice, “far from home, like you.” He rose to his feet, and indicating a road branching off from the fork, he said to Saul, “You are a very worthy man. I would be most honored if you joined me.”

But Saul pointed in the direction of the other road. “My path lies this way,” he said.

“A very lonely road,” observed Fort.

“A very lonely road,” concurred Saul.

“Yet more privation and hardship lies ahead,” Fort cautioned. “You are old, your condition is weak.”

“My strength is made perfect in weakness,” Saul replied, as Fort helped him to his feet.

“Spoken like a wise old fool,” said Fort, with approval in his manner.

A robust laugh issued from Saul. “A wise old fool,” he agreed.

“I would bid you God speed,” said Fort, with a twinkle in his eye, “but you and God have not exactly reached a meeting of the minds in this regard.”

“And I would wish you God bless,” Saul responded, his manner mirthful, “but you and God have probably come to your own arrangement.”

They embraced. “God speed,” said Fort. “God bless,” said Saul. They broke off their embrace, then parted company and headed their separate ways, two wise old fools.


And so it came to pass, far along the road, that Fort related his encounter to a band of pilgrims from the land of Rho, making their way to The Place. And the travelers marveled over this wondrous account of the strange man who had apparently wasted his life serving such a God of infinite unyielding disdain.

“It is not easy being God’s servant,” Fort allowed.

And what do you think became of this strange man? they inquired.

“That I cannot tell you,” Fort replied. “But I can venture this - that this time around, on the last leg of his journey, my guess is that God did not sink his boat.”

Also see Book I.

Tuesday, January 24, 2012

Newt the Borderpath: Making the Case that Psychiatry is Not Allowed to Make

Picking up where we left off ...

Thanks to “the Goldwater Rule” embedded into the code of ethics of the American Psychiatric Association, it is unethical for psychiatrists to “offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

The rule was the direct outcome of more than a thousand psychiatrists venturing negative (totally un)professional opinions about 1964 Republican Presidential candidate Barry Goldwater in response to a Fact magazine survey.

The rule effectively precludes psychiatrists from publicly stating the obvious, namely that current Republican Presidential front-runner Newt Gingrinch is “a walking-talking DSM-IV Axis II, Cluster B special, displaying a suite of bizarre behaviors distributed along at least three diagnoses, including borderline personality disorder, narcissism, and antisocial personality disorder.”

Of all the crazy things, the framers of the Goldwater Rule almost certainly never envisioned the bizarre possibility of one of its own reaching exactly the opposite conclusion, namely how Newt’s abundant character flaws might actually make him a better President. This happened last week when psychiatrist Keith Ablow scribbled an over-the-top commentary to that effect on Fox News. The gist of his thesis was that the cold-blooded indifference Newt displayed in dumping his first two wives is precisely the quality required of our next President in being “direct and unsparing with the Congress, the American people and our allies.”

Ironically, any psychiatrist jumping in to refute Ablow’s nonsense can only do so at the risk of incurring disciplinary action by the APA. Okay, we know the dangers of judging people we have never met, but what about public figures we may know better than members of our own family? Clearly, the public interest demands critical evaluation from the psychiatric profession.

With Newt Gingrich, it turns out, the exercise is as easy as shooting fish in a barrel. To focus on just one incident:

In 1995, Newt Gingrich as House Speaker initiated a 22-day federal government shutdown. In the midst of the crisis, Gingrich attributed his hardline stance to a perceived “snub” from President Clinton, who purportedly did not talk to him during a flight on Air Force One to Israel for the funeral of assassinated Prime Minister Yitzhak Rabin.

I’m not sure which is worse: A man putting millions of Americans in jeopardy as a result over his own damaged ego, in total disregard for their concerns, or expecting his victims (the American public) to identify with his pain. It turns out that Clinton had photos of the two talking on the trip.

In an op-ed piece in the Feb 25, 2011 Washington Post, Gingrich recast his outrageous conduct as a stand on principle, blaming President Clinton for vetoing a Republican budget and the “liberal media” for misreporting the issue, claiming that the short-term pain of the shutdown set the stage for later budget deals.

“So, we faced a choice,” he wrote. “We could cave in and be accepted by the Washington establishment, or we could stand firm for a balanced budget for the American people.”

There really is no issue here: The only thing that psychiatrists should be arguing about is which diagnostic category to stick Newt in. Three of the Cluster B personality disorders come immediately to mind - narcissism, borderline, and antisocial - with some element of paranoia thrown in. But as psychiatrists and psychologists are quick to point out, personal pathology is far more fluid and subtle, not amenable to diagnostic boxes.

So let’s dispense with choosing between this diagnosis or that diagnosis and going with a bit of each. This is the approach Barbara Oakley took in her 2007 book “Evil Genes: Why Rome Fell, Hitler Rose, Enron Failed and My Sister Stole My Mother's Boyfriend,” which has received considerable play on this blog.

As you recall, Dr Oakley characterized certain individuals as “successfully sinister,” your classic Machiavellians - charismatic and ruthless - out for themselves at the expense of anyone unfortunate enough to happen to breathe the same air. Her Machiavellian poster boy is Chairman Mao, whom she describes as “the perfect borderpath,” exhibiting  clear elements of borderline and psycho/sociopathy (plus generous helpings of narcissism and paranoia).

In the chaos of China, to the considerable detriment of a quarter of the world’s population, Mao was able to exploit his pathology to attain a position of absolute power for more than three decades. In a democracy, a borderpath is inclined to reach a more modest pinnacle. To quote from one of my earlier pieces:

In politics, says Dr Oakley, an American-born Mao might have become a populist demagogue in the 1930s Huey Long mold (I will leave the obvious contemporary examples to others) ...

Do you detect an obvious contemporary example? With the stakes much higher? Pity that psychiatry can’t talk about it.

Challenging the Bipolar-Sex Conventional Wisdom

I just added a new article to mcmanweb, The Whole Bipolar Sex Thing, which had its genesis in a series of posts on HealthCentral. Following is an extract ...

The conventional wisdom is that (hypo)mania increases our sexual drive - often to the point of excess - while depression has the opposite effect. Goodwin and Jamison in their 2007 "Manic-Depressive Illness" note that Aretaeus of Cappadocia in the second century AD observed "a period of lewdness and shamelessness exists in the highest type of [manic] delirium."

The authors cite a number of studies showing increased sexual interest and behavior during mania or hypomania, and the DSM makes it official by including "sexual indiscretions" in manic and hypomanic episodes. It also notes "decrease in sexual interests or drive" during depression.

Okay, time to challenge that notion. A 2006 NIH-funded study of a large teen population found that those who were depressed were far more likely to engage in risky behaviors such as drug use and sex. The study corroborates earlier findings.

One aspect of depression is a feeling of being "clinically dead but breathing," the very opposite of the "feeling alive" states of mind we experience in pure mania and hypomania. But something else also tends to be going on - intense psychic pain. If the clinically dead aspect of depression is about feeling too little, our psychic pain is about feeling too much. In this tortured state of mind we tend to be desperate for release, and seek it in a variety of ways - from attempting suicide to over-eating and over-sleeping to alcohol and drug abuse to "retail therapy" to the flood of feel-good hormones from a warm embrace.

The feeling may quickly wear off, but so what? People who have never experienced depression cannot possibly understand.

Thus both sides of the bipolar equation find us at risk, up as well as down. Yes, it is true that we are more likely to lose interest in sex when we are depressed, but this should not mask the fact that in certain instances the very opposite may occur, replete with the full menu of life-altering consequences. Psychic pain has that kind of effect on us.

Do Bipolars Make the Best Lovers?

Does hypersexuality in mania and hypomania actually translate to being better in bed? We have no evidence.

What is reasonable to assume is that our ups intensify all our experiences, whether listening to music, enjoying food, watching a sunset, or having sex. Even our downs can add layers of richness to our existence.

But is it possible for those close to us to experience our subjective realities? The answer appears appears to be yes. Our states of mind can be contagious. Wrote Kay Jamison of Virginia Woof, citing one of her social circle: "I always felt on leaving her that I had drunk two excellent glasses of champagne. She was a life-enhancer."

But the very intensity of our world can also be very frightening to others. Virginia Woolf may have lit up her Bloomsbury circle, but she also drove poor husband Leonard nuts. Likewise, the intensity factor has a way of drowning out the rest of our surroundings, including the people around us.

So - let's make a few wild guesses about what happens when we take our enhanced subjective realities to the bedroom. When things go right, it appears that the intensity we bring to the moment jumpstarts the "normal" partner's intensity, and next thing both partners are experiencing the type of cosmic union you read about in the poetry of Rumi.

Sample verse: "You are the sky my spirit circles in."

But maybe things get too intense for the comfort of our partner, perhaps to the point where he or she no longer feels safe. Maybe we are so into our own needs and desires that we lose sensitivity to those of our partner. We fail to pick up vital signals. We fail to make the necessary adjustments. Sex is mind-blowing enough without adding bipolar to it. Thus, if we are prepared to brag about how bipolars make the best lovers, we also need to accept the fact that there are times when we are probably the worst.

The "Bipolar-By-Proxy" Complication

Jumpstarting our partners may have the effect of turning them into "bipolar-by-proxy." This is wildly speculative, but let's run with it. If our partner is feeling the same kind of intensity we are feeling, with similar dopamine surges, then their capacity to make rational decisions may be as impaired as ours, perhaps more so. We at least have an experiential context to place our current state of intensity. Our partner may confuse this novel experience with love.

For the full article, check out The Whole Bipolar Sex Thing

Monday, January 23, 2012

Newt and "The Goldwater Rule": Why Psychiatrists Will Not Tell You the Obvious

“Newt Gingrich’s three marriages mean he might make a strong president - really,” ran the headline to a Fox News article published last Friday. What else would you expect from the publicity arm of the Republican Party? The twist was the article was written by a psychiatrist, not just any psychiatrist, a psychiatrist employed by Fox News, Fox News’ house psychiatrist Keith Ablow. Dr Ablow also co-authored a book with Glenn Beck and makes a decent living as a celebrity psychiatrist who has appeared on Oprah and other shows.

In his Friday article, Dr Ablow made the extraordinary claim that Newt Gingrich’s marital infidelities might actually make him a better President. The article was a response to allegations from his second wife that surfaced the day before. On Saturday, Gingrich handily won the South Carolina Republican Primary. Wrote Ablow:

When three women want to sign on for life with a man who is now running for president, I worry more about whether we’ll be clamoring for a third Gingrich term, not whether we’ll want to let him go after one.

Ablow also cited Newt’s cold-blooded indifference to his first two wives as a virtue. Really, I am not making this up. In Ablow’s words:

Two women - Mr. Gingrich’s first two wives - have sat down with him while he delivered to them incredibly painful truths: that he no longer loved them as he did before, that he had fallen in love with other women and that he needed to follow his heart, despite the great price he would pay financially and the risk he would be taking with his reputation.

Conclusion: I can only hope Mr. Gingrich will be as direct and unsparing with the Congress, the American people and our allies. If this nation must now move with conviction in the direction of its heart, Newt Gingrich is obviously no stranger to that journey.

Ablow’s article raises a host of issues, the most obvious being why a man speaking as a psychiatrist would be penning such nonsense. Shouldn’t it be the other way around? Shouldn’t we be hearing from a panel of mental health professionals on why Newt is psychologically unfit to hold high office?

The reason you are only hearing journalists and lay commentators ruminating on Newt’s (and other candidates’) putative craziness has to do with psychiatry’s “Goldwater Rule.” Some background:

In 1964, a month before the Presidential election, Fact magazine went to press with this headline: “1,189 Psychiatrists Say Goldwater is Psychologically Unfit to be President!”

The Republican candidate Senator Barry Goldwater of Arizona was a conservative ahead of his time. By 1980, when Reagan swept into office, his ideas were mainstream. By today’s standards, Goldwater would be considered a moderate and on some issues a liberal. By any standard, he was a man of high moral character. Ironically, it was his rival LBJ who would unravel in the Oval Office (see my two posts: Was LBJ Bipolar? The Case For, The Case Against).

Fact magazine sent questionnaires to 12,356 psychiatrists listed by the American Medical Association. Of the 2,417 who replied, 1,189 called him unfit. The eagerness of such a large percentage of its membership to issue summary personal judgments disguised as professional opinions alarmed the powers-that-be to the point that six years later, the American Psychiatric Association issued section 7.3 of its code of ethics that reads in part:

... it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

The section is only binding on psychiatrists, but clearly psychologists feel constrained by it. The “Goldwater Rule” is why you don’t hear psychiatrists or psychologists stating the obvious: That Newt is a walking-talking DSM-IV Axis II, Cluster B special, displaying a suite of bizarre behaviors distributed along at least three diagnoses, including borderline personality disorder, narcissism, and antisocial personality disorder.

Mind you, as Nassir Ghaemi made abundantly clear in his 2011 book “A First-Rate Madness,” we don’t want our public figures overly normal, either. In certain situations, a bit crazy can be good.

Clearly, the public would be served by hearing an educated discussion on the matter, but the APA does not trust its members enough to restrain themselves. This brings us back to the Ablow’s off-the-wall Fox News piece. Did he breach the Goldwater Rule?

The framers of section 7.3 almost certainly did not foresee the possibility of one of its own employing twisted logic to turn appalling behavior into a character virtue. Had it been the other way around - had another psychiatrist sounding off on MSNBC reached the more obvious conclusion - we would probably hear Fox News screaming for that individual’s head.

That’s how crazy things are.

Much more to come ...

Friday, January 20, 2012

The Book of Fort

The other day, while hiking in the mountains, I came across some ancient writings secreted in a cave. Clearly, they are Scripture from a forgotten people. I just finished translating the first scroll ...

And there lived in the land of Gob a righteous man named Fort, who was a crafter of fine hardwood didgeridoos. And his didgeridoos were strong and resonant and affordable and brought great joy to the people of Gob. And so it was that Fort prospered. And as he aged, he would preface his comments with, “When I was young and foolish ...” And thus the people of Gob came to regard Fort as old and wise, and indeed he was.

One day a seeker of wisdom appeared in his didgeridoo shop and asked: “Wise Fort, show me God.” And Fort replied, “Alas, son, I cannot do that, for I do not presume to know God." And the seeker asked: “Wise Fort, explain to me the meaning of life.” And Fort replied, “Alas, son, I cannot do that, for I do not presume to understand the mysteries of life.”

And the seeker asked: “Wise Fort, show me how to make a didgeridoo.”

And Fort replied: “Come closer, my son. That I can show you.”


And so it passed that an ox gored a young man to death, which would have been of no account but for the fact that the ox and young man had two different owners. And the owner of the young man sought restitution from the owner of the ox. But the owner of the ox refused, claiming that an ox of high status had every right to gore to death a young man of no status.

And this would have been accepted as entirely reasonable had the man of no status been owned by a man of low status. Alas, the man of no status was owned by a man of high status. And so a great dispute arose in the land of Gob, and neighbor began regarding neighbor in the type of reproachful manner that recalled the Dark Times that ended the Golden Age that preceded the Day of Reconciliation that gave rise to the Era For Which There is No Name.

Surely, they said, God must have anticipated an event of this nature would occur. And if that is so, they reasoned, then God must have anticipated all manner of events, and so must have come up with laws to govern the entire realm of human endeavor. And if that were so, then God would have provided clear rules to resolve all disputes.

Therefore, the people of Gob reasoned, God must have issued a Code. And so it was that the people of Gob called upon Fort, crafter of fine didgeridoos, to go to the top of the mountain for forty days and forty nights - or 40 nights and 40 days, whichever came first - seek out God, and return with the Code.

Forty nights and forty-one days later - or forty days, accounting for time off - Fort returned from the mountain with a large rock shaped like a tablet.

Did you return with God’s Code? asked the people of the Land of Gob.

I did not, replied Fort. But I did come across this rock with some writing on it.

Surely, they said, that must be the word of God.

Judge for yourself, said Fort.

What does the Code say? the people of Gob enquired.

And spoke Fort, It says thus:

“The stupidest idea - indeed must odious, most pernicious - ever devised by Man is that certain men regard themselves as superior to others and others as inferior to themselves.”

That is all that God says? asked the people of Gob.

That is all the rock says, replied Fort.

And the people of Gob pondered the matter for days into weeks and concluded that the rock conveyed wisdom that was far beyond the realm of mere mortals and so must be the Word of God. And having been singled out by God, they concluded that they must indeed be special. And they resolved to live by God’s Code.

And by living by God’s Code, they immediately regarded themselves as superior to others and others as inferior to themselves.


And so it came to pass that the most superior of the superior people in the land of Gob reasoned thus: If God possessed the wisdom to issue a Code of such profound infinitude - or infinite profunditude, as the case may be - His thinking has to be nuanced beyond imagination.

And indeed, if this is so, then God must have issued a longer Code, a Code in two parts, the second part which would have contained exceptions to the first part. And so they dispatched a delegation of Elders to the top of the mountain to find the second tablet which would have contained the second part of the Code.

Alas, the Elders failed to return with the second tablet, but by now, thanks to the wisdom conferred by the first tablet, they now possessed the insight to deduce the wisdom of the missing second tablet, and so came up with a long and detailed list of exceptions to the first.

And this list of exceptions was loudly acclaimed by the people of the land of Gob, especially among the superior of superiors. And thus the Era For Which There Is No Name gave rise to the Era of Great Prosperity, at least according to some.

More to come ...

Wednesday, January 18, 2012

Incompetence in Psychiatry: Readers Weigh In

“What percentage of psychiatrists do you think are incompetent?” I asked in a reader poll that ran some six weeks during December and January. Framing my question negatively carries the strong risk of encouraging rotten tomatoes responses and thus undermining the credibility of any findings, but my attempts at positive construction came out totally pathetic. Sometimes negative is the best option.

Eight-nine readers responded to the poll. The poll makes no claim to scientific validity, but I know you’re sure as hell interested in the answers ...

The major finding: 32 percent of you - nearly one in three - thought that more than two-thirds of psychiatrists were incompetent. One in five of you (19 percent) pegged psychiatric incompetence in the 51 percent- 66 percent range (more than half, up to two-thirds).

So - more than half of you think that more than half of psychiatrists are incompetent.

Over on the other end of the scale, just one in four of you (25 percent) thought that a third or less of psychiatrists were incompetent. Only one third of this twenty-five percent (less than one in ten overall) regarded ten percent or less of psychiatrists in the incompetent range. One in five overall (19 percent) responded in the one-third or more to one-half incompetence range.

Okay, how much incompetence in the field are we willing to tolerate? One-third? How comfortable would you feel about boarding a flight if you thought one-third of the pilots were incompetent? How about another branch of medicine, say brain surgery? Nope - doesn’t cut it. Neither does 10 percent, nor, for that matter, does one percent.

So here is what I hear you saying: Three-quarters of you (75 percent) are telling me that you think that a full one-third or more of the people we entrust our lives to have no business practicing psychiatry. More than nine in ten of you (92 percent) are telling me that you think at least one in ten psychiatrists is incompetent.

Mind you, this poll is about your perceptions rather than reality, but your perceptions are what’s important. And if your views are even the slightest bit representative of a wider patient-family member population, then - truly - interventions of biblical dimensions are called for.

Before we get carried away, the practice of psychiatry hardly lends itself to objective judging criteria. In my own field of journalism, a 2010 Gallup Poll reports that only 25 percent of the American public has confidence in newspapers and only 22 percent in television news. (I’m not sure which is the more frightening interpretation - that so many have lost confidence in my profession or that an uncomfortably high percentage of the public actually believes the crap they come across in the media.)

Thus, to be fair to psychiatry, any discipline that operates in the subjective realm is bound to draw a lot of heat, justified or not.

But there is another factor involved: Most incompetent people do not know they are incompetent. A 2000 NY Times article cites research in support of the proposition that the incompetent lack the skills to monitor and evaluate their own performance, thereby perpetuating their clueless behavior.

Research shows that the vast majority of people rate themselves as “above average” across a broad band of abilities. In one study that tested subjects for grammar, for instance, those who had scored around the bottom guessed that they had scored well above the mean. Conversely, the highly skilled are likely to underestimate their competence.

In the words of Thomas Jefferson:  "He who knows best knows how little he knows."

Is your psychiatrist aware of that?

Monday, January 16, 2012

Rerun: We Still Have a Dream

Like anybody, I would like to live a long life. Longevity has its place. But I'm not concerned about that now. I just want to do God's will. And He's allowed me to go up to the mountain. And I've looked over. And I've seen the Promised Land. I may not get there with you. But I want you to know tonight, that we, as a people, will get to the promised land!

Dual Diagnosis, Co-Occurring Disorder: How Bad Is it?

I just added two segments to my mcmanweb article, When Mood Meets Alcohol and Substance Use. The two segments help open and close the article, but surprisingly they work together as a blog piece without the intervening content. Without further ado ...

In the fall of 2011, I experienced an aha! moment into the true severity of this condition. I was having dinner with a group of individuals involved in NAMI (National Alliance on Mental Illness). NAMI was founded in the late seventies by parents with kids with schizophrenia and all these years later these individuals still form the core of the organization's membership.

Inevitably, the conversation turned to their kids. The intractable nature of their illness, the heartbreak they put their families through, hospitalizations, homelessness, run-ins with the law, on and on. Naturally, I assumed they were talking about schizophrenia. Then one parent mentioned bipolar, then another, then another.

Bipolar? For the most part, even those facing severe challenges manage to settle into some kind of quasi-life. Yes, all hell may occasionally break loose, but the emphasis is on occasional. What I was hearing was different, way different.

You guessed it. It wasn't "just bipolar" I was hearing about. Thanks to drug and alcohol abuse in the equation, life's degree of difficulty for all parties concerned went from "challenging" to "just about impossible." The stories that night jibed with other accounts I had heard over the years from parents and loved ones, plus no end of conversations I have had with individuals experiencing the condition.

How bad is it? Recall, at first I thought these parents were talking about schizophrenia. That's how bad it is. 

Many people I have met in DBSA support groups clearly benefit from also attending AA and NA, but there are limits to this type of divided support. The divide exists across clinical services, as well - with sharply segregated specialities operating in their own isolated silos - despite the fact that expert opinion strongly supports integrated treatment. How ridiculous is that? Consider this passage from Voltaire's "Zadig."

Zadig was more dangerously wounded; an arrow had pierced him near his eye, and penetrated to a considerable depth. ... A messenger was immediately dispatched to Memphis for the great physician Hermes, who came with a numerous retinue. He visited the patient and declared that he would lose his eye. He even foretold the day and hour when this fatal event would happen. "Had it been the right eye," said he, "I could easily have cured it; but the wounds of the left eye are incurable." All Babylon lamented the fate of Zadig, and admired the profound knowledge of Hermes.

In two days the abscess broke of its own accord and Zadig was perfectly cured. Hermes wrote a book to prove that it ought not to have been cured. Zadig did not read it ...

So here we are, our entire treatment and support system in a state of myopia, with doctors of the left eye and doctors of the right eye not talking to each other, totally blind to the real phenomenon - dual diagnosis, co-occurring disorder, whatever you want to call it. Again, how bad is it? Recall my aha! moment with those NAMI parents.  

Friday, January 13, 2012

Reality Intervenes: The Case for Meds

Yesterday, in a piece entitled, We Can All Get Along, Can't We?, I wrote:

Psychiatry and its over-reliance on medications is experiencing a current self-inflicted lack of respect. This is occurring at the same time as Big Pharma is pulling out of the business of new psychiatric meds development. A new generation of psychiatrists pushing the same old meds serving up the same old explanations simply defies credibility.

Just so we're clear: In no way should this be interpreted as antipathy towards meds and those who prescribe them, much less those who take them, not to mention their family members and loved ones. As much as I may rail against the mindless overprescription of meds, I also realize there is a time and a place. Within hours of writing the above, I was served up a very strong reminder, three of them, actually.

First Reminder

Soon after posting my blog piece, I headed out the door and across town to check out this month’s International Bipolar Foundation lecture. The speaker was Maricela Estrada (pictured here), author of “Bipolar Girl: My Psychotic Self, a Memoir,” self-published in 2009. I arrived early and thus had a chance to have a one-on-one conversation with the author. Maricela is in her early 30s and works as a peer specialist for the Department of Mental Health in LA. She has an engaging manner and a delightfully bubbly personality, and in no time we were laughing and joking.

Maricela is no stranger to depression. She experienced her first episode as a school girl and has survived numerous suicide attempts, not to mention a drive-by shooting where a bullet whizzed past her head as she was lying in bed. The depressions continued through high school, but could not extinguish her irrepressible high spirits. She was very popular as a student, involved in activities, and elected prom queen.

Things fell apart soon after graduation. Mania, psychotic breaks, more suicide attempts, hospitalizations. During stable periods she managed to hold down various jobs and excel in college. But she would go off her meds and things would unravel. One time, in a car in a parking lot, she was convinced the world was ending. She heard a chorus of angels. She started screaming at people, and stripped off her blouse in order to be as naked as Adam and Eve. She was apprehended and handcuffed and put into a police car, breasts exposed.

In due course Maricela ended her denial and accepted the fact that she needed to stay on her meds. The meds were no picnic, and she had to struggle with weight gain and feeling like a zombie. In her talk she reported that she is now on a regimen she is happy with. In response to a question from the audience, she mentioned she loved her medication.

Thanks to her meds, she is in a position to say that.

Second Reminder

Just before Maricela was to speak, a woman I hadn’t seen in years walked into the lecture theater and took a seat next to me. Last time we talked, her husband, not on meds, had taken off and uprooted to another state. These kind of stories rarely have happy endings. Judy Eron’s “What Goes Up” recounts one such personal tragedy.

Fortunately for this woman, some 18 or so months later her husband eventually returned and got on lithium. Happy ending. Well, actually, there are no such things as endings so long as life goes on. For the two - thankfully - life goes on. So does their marriage.

Third Reminder

A few days ago, in response to an article on child bipolar, someone posted on mcmanweb:

Parents are being mislead by a multi billion-dollar a year child drugging industry that a diagnoses of "mental disorder" (ADHD, Bi-Polar, Social Anxiety Disorder) are medical diseases or illnesses. This is a fraud. No child has a brain scan, blood test, X-Ray or any evidence of physical abnormality to verify they are "ill" or "diseased." 

Yet psychiatrists continue to pound the public with misleading and fraudulent statements that these so called mental disorders are biochemical or neurological conditions. That is false. They are simply a list of behaviors that psychiatrists vote into existence and insert into their billing bible, the Diagnostic and Statistical Manual of Mental Disorders.

This has led to over 8 million children in the U.S. taking mind-altering psychiatric drugs.

This morning, I woke up to this response from Terea:

Mental disorders aren't something you have to "believe in" to be real. I once had my doubts about ADHD, but now that I have a 6 year old son with bipolar disorder and ADHD I know how important it is for these kids to receive an accurate and timely diagnosis. My son would stay up for nights on end, do dangerous and risky things, he couldn't function in school, he could barely talk, and even though he was frequently climbing walls he was a very unhappy little boy. 

Terea went on to say:

Now my son is taking Seroquel at night and Concerta during the day and life is so much better, not just for our family but for him as well. Grant can sleep, he is making friends, he is happy most of the time and not manic, and he is starting to read! In deciding whether to treat my child with "mind altering drugs" my choice was easy. It is absolutely apparent that Grant's quality of life is better now than it was before receiving treatment. If my child needed diabetes medicine I would make sure he got it, and the same goes for his bipolar meds. Finally, I look to my son's future and I know what happens when bipolar disorder is not treated. 

She wasn't through:

My dad committed suicide when I was a teenager and my brother has been on and off illegal drugs since his diagnosis in his late teens. I also have friends with bipolar disorder. You can't just ignore it and it will go away. With a 15% successful suicide rate untreated, self-medication, and all the other problems that arise when a mental disorder is unchecked, it is my responsibility as Grant's parent to do whatever I can to help him deal with his bipolar disorder...and not just ignore it.

Moral to this story

Well, it's rather obvious, isn't it?

Thursday, January 12, 2012

We Can All Get Along - Can't We?

Last week, I killed off the term, “antipsychiatry.” These days, we only hear the word used as an insult, too often in the context of attempting to discredit even mild critics of psychiatry. 

I may know what I mean when I use the A-word, but others hear it in a different way. They hear it as a weapon to silence skeptical enquiry, to discredit the recovery movement, and - worst of all - to devalue the personal experiences of those who have stories to tell.

So - good riddance to the term. Yes, there is a fringe element out there, but we’re going to have to find a new way to describe them. In the meantime, it is useful to focus on what we all appear to agree on. Forgive me if this all seems obvious, but that is the very point of this little exercise ...

We all believe in recovery.

Not only that, we’re in general agreement on the things we need to be doing to achieve recovery. These may vary widely from individual to individual, but there is a very broad consensus that meds are only a small part of the equation. The real work - which tends to involve accepting brutal realities, making tough decisions, and implementing serious lifestyle changes - is up to us.

It goes without saying that settling for badly compromised existences in the name of stability is wholly unacceptable, but I’ll say it anyway.

We all believe in mental illness.

When we happen to describe the hells we’ve had to endure and the unbearable pain we’ve been through, we’re not just making this up. This is not psychiatry labeling us or pathologizing our behavior. By the time we come to the attention of the psychiatric profession, we have already performed a spectacularly successful job of wrecking our lives beyond recognition. We want the pain to stop - at any cost - and sadly too many of us wind up choosing what we think is the only way out.

We can argue all we want about what to call it and how to define it - much less how to treat it - but when all is said and done, we tend to be fairly relieved when we discover that someone has a name for it. Call it “Fred,” for all I care. 

We all want to know what the hell is really going on.

Brain science is yielding spectacular new insights on the interactions between our genetic makeup and the environments inside and outside of us. This in turn is forcing us to rethink human behavior from every conceivable angle. The one thing we know for sure is that we don’t know very much, which means literally every idea is on the table. No one has an easy answer, which means rigid belief systems no longer cut it with us.

But - oh! - the thrill of discovery. A new piece of evidence, a new insight, a new revelation. We connect our own dots. We draw our own conclusions. We make our own decisions.

We all realize the paradigm is changing.

Psychiatry and its over-reliance on medications is experiencing a current self-inflicted lack of respect. This is occurring at the same time as Big Pharma is pulling out of the business of new psychiatric meds development. A new generation of psychiatrists pushing the same old meds serving up the same old explanations simply defies credibility. 

Thankfully, a new science of the mind is emerging, along with a consumer-driven recovery movement. Psychiatry can choose to be part of both, but when the dust settles it is highly unlikely that as an institution it will be leading either.

We all respect each other.

There may be a general consensus on the same issues, but our own diverse experiences and ways of looking at the facts guarantee that no two people are going to agree with each other on all issues all the time. Thank heaven for that.     

Friday, January 6, 2012

R.I.P. "Antipsychiatry," the Term

Following is a piece of a comment posted yesterday by KA on mcmanweb:

... No one is saying "anti-psychiatry is right" because anti-psychiatry isn't a belief system. It can't be right. It's an open-ended criticism. Skepticism is not a position; it's a process.

In my article, Stupid Advocacy Kills, based on blog pieces here, I attacked antipsychiatry for its obstinate denial, in complete defiance of the facts, that “mental illness exists in the first place, along with the possibility of finding treatments ...”

Trust me, notwithstanding KA, I view antipsychiatry as a rigid belief system that has nothing to do with open-ended enquiry, but if I have to explain myself every time I use the term, well, perhaps I should be looking around something better.

This came through loud and clear when Corinna West - a recovery advocate I hold in high regard - posted this two months earlier in response to a piece here on Knowledge is Necessity:

... I do ask, please, that you correctly identify those of us that are psychiatric survivors and leaders of our mental health recovery civil rights movement. Antipsychiatrists are completely different people with different agendas. Folks like to use the antipsychiatry insult to denigrate our work, and lumping us together is just about as inaccurate as trying to rebut Whitaker.

Ms West was referring to my attack on Robert Whitaker’s “mindlessly unqualified endorsements of the antipsychiatry movement and his ill-informed cheap shots against advocacy groups that actually get off their asses and help people ...”

The piece, Rebutting Whitaker: Not Such a Good Idea, was actually very supportive of Whitaker and highly critical of psychiatry’s response (and nonresponse) to his book, Anatomy of an Epidemic.

Do you see a problem here? Practically every person with a brain or someone who knows someone with a brain - myself included - has massive reservations concerning both the practice of psychiatry and what passes for its scientific underpinnings. But we hardly define ourselves according to our negative orientations, nor do we want to be mistaken for those who do. We ARE the 99 percent - the rigorously enquiring pro-recovery majority.

Yes, there is an anti-intellectual, anti-science nihilist fringe out there, but is there a better term for describing them than antipsychiatry? Yes there is - let’s call them the anti-intellectual, anti-science nihilist fringe.