Reckoning with Evil

This is my third installment in our conversation on Nassir Ghaemi’s “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness.” In our previous two pieces, Dr Ghaemi indicated he is no fan of normal, at least not in crisis situations that call for individuals (such as Churchill) with at least some practical experience in crazy

In my second installment - Normal: It Ain’t What It’s Cracked Up to Be - I mentioned a study reported by Dr Ghaemi that found that so-called mentally healthy individuals suffered a bad case of average-itis. These well-adjusted individuals tended to fit in rather than rock the boat. Not that there’s anything wrong with that. It’s just that, in a crunch, you don’t send in a normal person to do a crazy man’s job.

So far, so good. But in our first installment - The Normal Paradox - I also outlined an extremely contentious proposition advanced by Dr Ghaemi, one having to do with “normal” as a strong contributing factor to Nixon and George W Bush making bad decisions. In other words, humans are perfectly capable of exercising appalling judgment on their own account, with no assist from any condition with a DSM pedigree.

But Nixon had to have been crazy, you may well counter. Indeed, maybe he was. But the point is that he didn’t have to be, and neither does anyone else. Normal people have committed the worst atrocities imaginable. Enter Ghaemi’s next case study, Adolph Hitler.

First the black box warning: Reconceptualizing Hitler is bound to raise intense reactions. I totally respect that. I’m not even asking you to keep an open mind.

Way way back, on mcmanweb, I reviewed Hershman and Lieb’s “Brotherhood of Tyrants,” which attributed Hitler’s atrocities to bipolar. No, I said in effect. True, the evidence for Hitler’s bipolar is compelling, but not everyone with a mood disorder invades Poland. It had to have been sociopathy.

Not really, says Dr Ghaemi. We start with impossible-to-ignore documentation of Hitler’s depressions and (hypo)manias, but until 1937, Ghaemi contends, Hitler’s condition “seemed manageable.” That changed when he started to take amphetamines.

In 1937, Hitler began treatment with a new personal physician, Theodor Morell, who stayed on till nearly the end. Dr Morell prescribed amphetamines for depression (and a narcotic and other drugs for GI problems and barbiturates for sleep). Confidantes such as Hess and Himmler immediately noted the change in their boss’ behavior. In 1941, there is evidence Hitler was taking amphetamines intravenously on a daily basis, supplemented by oral doses. By 1943, he was receiving multiple daily injections.

Dr Ghaemi points out that oral amphetamines cause mania in about half of individuals with bipolar, with a much greater certainty with intravenous injections. Rats are deliberately injected with amphetamines to produce an animal model of psychosis. As thoroughly odious has Hitler had been, Ghaemi observes, citing Bullock, he was a realistic and astute politician. Moreover, he hadn’t invaded any countries, nor had he turned genocidal. As Ghaemi describes it: “Morell lit a fuse that exploded the entire world.”

Thus, up to 1937, Hitler’s bipolar benefited him in a way that influenced his rise to power, “fueling his charisma, his resilience, and political creativity.”

Ghaemi acknowledges that Hitler had always been an angry man, but that he had generally been “courteous and proper” in social settings. By 1942 (after the war had turned against him) Hitler was routinely screaming at his generals. Whereas he used to have no trouble delegating authority, now he became obsessed with details. His doctor only made things worse by intensifying the quack treatments.

Okay, so how do we account for Nazism in the first place? Or, for that matter, any evil?  What about Hitler’s henchmen? How sick were they?

After the War, Ghaemi tells us, the Allies put two dozen high-ranking Nazis  (including Goering and Ribbentrop) through extensive psychiatric evaluation and psychological testing, which went on for two years. The evaluations revealed that these men were normal. Goering, for instance, according to one investigator, had a “normal basic personality,” though “he was cynical and filled with mystical fatalism.”

Hitler’s criminals went to their deaths, totally impenitent, very pleasant people to talk to, righteous to the end.

Are we ever going to understand evil? Probably not. Are we making a serious mistake always associating evil with crazy? Definitely so. Evil, unspeakable evil, lurks everywhere. Crazy is not a requirement. Normal works very well with evil. Until we come to terms with this shocking fact of life, evil will continue to flourish, barely contested. That’s been our long past. Our futures may turn out short. 

Didgeridoo Diplomacy - Honking For Mental Health Awareness

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

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

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

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

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

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

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

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

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

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

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

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

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

Black Box Warning: Something Good About Ayn Rand

As part of “Put Ayn Rand on a Spit and Roast Slowly Week,” we compared the movie version of “Atlas Shrugged” to “Santa Claus Conquers the Martians,” unmasked her as “666” in the 2008 financial-economic apocalypse, and exposed her silly objectivist philosophizing as a fraud.

Okay, I know you’re not going to believe this, but Rand’s strongest critics back in her day weren’t communist sympathizers or left-wing intellectuals (or for that matter anyone with half a brain). No, it was the far right. This from a 1957 review of Atlas Shrugged by Whitaker Chambers in William Buckley’s National Review:

Out of a lifetime of reading, I can recall no other book in which a tone of overriding arrogance was so implacably sustained. Its shrillness is without reprieve. Its dogmatism is without appeal.

“To a gas chamber - go!” the review concluded.

In 1964, Buckley condemned "her desiccated philosophy's conclusive incompatibility with the conservative's emphasis on transcendence, intellectual and moral," comparing her unyielding dogmatism to the likes of Savonarola (the fanatical Florentine monk who burned books and works of art during the Renaissance).

Forgive me, but any enemy of the far right is a friend of mine.

Buckley’s major contribution to the conservative movement was in cloaking an essentially Visigoth creed in a veneer of civility. The far right, back in those days, had image problems. A country which had prospered and achieved world leadership under FDR and Truman (and let’s give Ike credit, too) was not about to display its gratitude by voting back into office the same people who had inflicted upon them the Great Depression, unemployment, bread lines, social injustice, isolationism, and union-busting.

By branding himself as a conservative that liberals could stomach, Buckley is credited for setting the scene for the Reagan Presidency and the unrelenting sorry mess that followed. But first, he had to purge those who might blow his cover. Segregationists and McCarthyites who essentially knew how to hold a knife and fork correctly were allowed to remain members in good standing. (Buckley was both a white supremacist and an ardent defender of the McCarthy anti-communist witch hunts.)  Anti-Semites (even those with good table manners) were not. Robert Welch, founder of the John Birch Society, was too much of a loose cannon.

Then there was Ayn Rand. As well as being an atheist (she once told Buckley, an observant Catholic, that he was too smart to believe in God), she preached a gospel of naked (she called it rational) self-interest.

Every right-winger worth his salt, Buckley included, believed in exactly the same thing. Free enterprise is based on the principle, and you can make a very good case that it serves the public interest far better than any system that claims to act in the greater good. I have greatly benefited from living in a society based on naked self-interest - I’m not stupid.

Ayn Rand sneered at the idea of altruism, but she wasn’t exactly against it, and it would be unfair to pin this rap on her. What she was against was forced altruism. According to Rand, that’s where the trouble starts, and she witnessed it first-hand in her native Russia after Lenin’s Bolsheviks took over. Once the greater good comes into play, it is time to get the hell out of Dodge. No longer does the state serve the individual. Rather, the individual serves the state. Always with catastrophic results.

Yes, we all long to be part of something greater than ourselves, but there exist no shortage of evil people most happy to exploit this noble side of our nature.

Obviously, the greater good was by no means a communist monopoly. Propagandists such as William Buckley needed to use it to make their case for a kinder and gentler brand of “screw-you-I’m-rich” conservatism. It also helped if they could use religion as a club to beat dissenters over the head.

But here was Ayn Rand, telling it like it was, undermining Buckley. Give Ayn Rand full marks for her honesty and courage. I came of age during the sixties. I read Buckley’s columns. I watched him on “Firing Line.” For all his collegial bantering with the likes of liberals such as John Kenneth Galbraith, this man was an enemy of democracy.

Make no mistake, it is the far right who originated politically correct. If you don't believe me, cast your mind back to the flag-burning amendment controversy and the people who supported it. Also, check the credentials of those who lead book burnings.

Heaven help back in the day if you believed in racial equality or social justice - that made you a communist. Heaven help if you objected to poor young boys being drafted to fight an ill-conceived war - that made you an some kind of traitor.

“Love it or leave it,” appeared on the bumper stickers of the day, and leading the chorus was the glib and smooth-talking Bill Buckley.

So whenever “the greater good” comes up in the name of country or religion of some other ideal, we need to pay attention to Ayn Rand. I’m proud to consider myself altruistic. I freely give my time to individuals and worthy causes. But when it comes to forced altruism - of someone else telling me how to think and behave and what stupid war I'm supposed to die in - put me foursquare in Rand’s corner.

Of all things, Ayn Rand has now become a right-wing folk hero, but probably only because Fox News has neglected to inform its viewers that their new role model was rabidly atheist, pro-abortion, slept around quite a bit, was ethnically Jewish, and insisted on marching to her own drum.

The world is a funny place ...

Hagop Akiskal's Theory of Practically Everything

I've been running a number of pieces on Hagop Akiskal lately, based on a talk he gave recently to DBSA San Diego. The pieces touched lightly on Dr Akiskal's highly original observations on the interaction between mood and temperament. Below is the heavy-duty complex version, pulled from a 2006 article on mcmanweb. 

Please don't feel you need to comprehend the piece. My intention, rather, is to give you an appreciation for a deep thinker's insights into the complexities of human behavior ...

Do fear and anger underpin practically every mood and personality state? What kind of crazy question is that?

Hagop Akiskal MD of the University of California at San Diego thinks he may have an answer. Dr Akiskal is no fan of the DSM approach of separating out psychiatric phenomena into neat diagnostic parcels. The dynamics of mood and temperament, and their interactions, are far too messy for that, especially when they involve mixed depressions that behave suspiciously like bipolar disorder.

In two online advance articles from The Journal of Affective Disorders in 2006, with Brazilian collaborator Diogo Lara MD as one of his co-authors, Dr Akiskal has proposed what can best be described as a "fear-anger dysregulation hypothesis."

Dr Akiskal broadly divides personality into four temperaments, including hyperthymic, cyclothymic, depressive, and anxious, each conferring certain adaptive advantages. Hyperthymics are the leaders, energetic and upbeat. Cyclothymics are the creative romantics. Depressives tend to be subservient (someone has to take orders and do the grunt work), while anxious types lean toward altruism. These traits are distributed along a continuum ranging in degree from normal and supernormal to the sturm and drang of mood disorders.

This is where Drs Akiskal and Lara drop their bombshell. In the first of their two articles, the authors advance the notion that "basic mood states, both normal and pathological, can be conceived mostly as a function of transiently dysregulated or accentuated fear and anger traits." Moreover, they submit that "their combinations and various permutations can predict all major mood profiles, both pathological and healthy."

Whoa! Fear and anger for ALL of mood, healthy and otherwise? Is this the new E=MC2 of psychiatry?

"Fear is the path of the Dark Side. Fear leads to anger, anger leads to hate, hate leads to suffering." Is it really that simple? Is cutting edge psychiatry nothing more than a remedial attempt to catch up to Master Yoda?

Okay, let's assume that Dr Akiskal has not seen too many Star Wars movies. First, let's clear up what Dr Akiskal means by anger, which is not necessarily what you encountered as a kid when you tracked mud over your mom's freshly-waxed kitchen floor. When high anger is coupled with low fear, we are talking about the "sunny side," characterized by pleasure seeking and grandiosity. But add more fear to the mix and we arrive at anger's more familiar "dark side."

Oops, maybe Dr Akiskal has watched too much Star Wars, after all.

Earlier mood spectrum models call for thinking linearly, in one dimension. Now, Dr Akiskal asks us to think bi-dimensionally.

Thinking Inside the Box

Drs Akiskal and Lara ask you to imagine a square tipped on one corner, sort of like a diamond-shaped compass.

The "north" pole is "hyperthymic," bracketed by low fear and high anger. The "south" pole, "depression," is bracketed by low anger and high fear. Now add a west-east axis and you get something like this:

Say the authors: "Since cyclothymic and hyperthymic temperaments predispose to bipolar disorder, high anger would be the distinguishing feature of bipolar spectrum disorders." In bipolar disorder, fear modulates the anger. The authors contend that their model also applies to behavioral characteristics that are not disorders, such as entrepreneurship and leadership in hyperthymic individuals. The model does not cover schizophrenia, schizoaffective, and schizoid personality disorder, nor pervasive developmental disorder.

Thinking Inside the Box - Part II

The authors have thoughtfully provided an additional tilted square. Depressive stays the same, but this time "euphoric" occupies the opposite pole, while "dysphoric" becomes labile's opposite. Plus some additional blanks (simplified here) are filled in, as such:

Various manic and hypomanic states (with short-lived depressions) occupy the top part of the square just below euphoric (M,H,d). Working down from euphoric to dysphoric, pure mania gives way to mixed states and cycling (mx, cy). Working the other way from euphoric to labile, mania gives way to attention deficit/hyperactivity and atypical depression (.ad/h, AD)

Down at the bottom we have depression (D) and dysthymia (dys) which merges into labile features working one way up the square and dysphoric the other way. Everything starts to quiet down as we approach euthymic from any direction.

As you can see, according to Drs Akiskal and Lara, not all depressions and manias are alike. Different types feed off differing degrees of fear and anger, typically high of one and low of the other, but often a mix of both. In their article, the authors add that atypical depression involves a "transient downregulation of anger traits," while cycling involves both high fear and high anger, "as one pulls up and the other pulls down."

More to come ...

Living Well ...

This is a clip from my appearance on "San Diego Living," XETV, Channel 6, shot live this morning.