Playing the Didgeridoo - Believe it or Not, I Used to Be Worse

This weekend, practicing at home, I played my didgeridoos - all four of them - as if I really knew how to play them. This wasn't always the case. This from the book I am working on, "Raccoons Respect My Piss - But Watch Out for Skunks: My Metaphor for Life on a Planet Not of My Choosing and How I Finally Came to Terms."


We pick up on the action three years ago ...

I was downtown for my third conference in six weeks, the NAMI national convention. I rolled in late in the afternoon, checked into my hotel, then headed over to the venue, in time to play my didgeridoo at the evening talent show. Trust me, didgeridoos make perfect sense in California. I lived in Australia for five years - wasn't interested. Then, not long after my arrival in my new neighborhood, I happened to walk into a coffee shop and walk out with a didgeridoo.

This one was made out of local desert yucca and had the look and dimensions of an alphorn. Most didgeridoos are way smaller.

I arrived home with my new purchase, perplexed at why I wasn’t able to master the thing in five minutes. I used to play the trombone. What could be so friggin’ hard about getting one note out of a glorified stalk of desert yucca? Don’t these things come with tech support?

I spent the ensuing week producing noises reminiscent of the beans scene from “Blazing Saddles.” The only reason I persisted was because I knew it could be done, sort of like the Wright Brothers. They were willing to put up with failure because - thanks to birds - they knew flight was possible.

But some guy or gal thousands of years ago picking up a hollow log in some pristine rain forest? How did he or she know “beyond flatulence” was feasible? What kept this person going? What on earth was going through his or her mind? The burning philosophical question.

By the end of the first week I had progressed to fog horn. But I could only sustain the sound for five seconds at best. I set to work on my newsletter, but there was my didge in the corner, mocking me. An hour later, hyperventilated and discouraged, I began asking myself, how well does yucca burn? One last toot. Something happened. Something that faintly resembled the sound of a didge.

Over the next few days, I was able to work on reliably producing the didge sound and sustaining it beyond five seconds. One day, I felt confident enough to take it out into the back yard. The woodpeckers offered encouraging percussive chatter. A hummingbird flitted over and checked me out. Good omen.

My backyard experiences started to take on a spiritual quality. By now I could get a drone going for twenty seconds, with a range of subtle tones and harmonic overlays. Looking out across to the mountains under a cobalt sky, I was able to produce the OM of the universe. Everything stems from vibration:

“When all things began, the Word already was … So the Word became flesh.”

Then I took my didge out under the night sky. Up at 3,500 feet, they polish the stars every night. For this particular occasion, the Forest Service had just finished lowering the moon to just above tree-top level and thoughtfully provided an ambient soundtrack of croaking frogs.

I held off on my didge, allowing myself to become one with my surroundings. Then, I brought the didge to my lips, content to just blow air through it. Finally, I was ready. I drew in a relaxed breath, and looking up at the canopy of the heavens, I sounded my OM into a frog-enriched cosmos.

Now, here I was at the NAMI conference, toting around my didgeridoo. For some reason, the sight of the thing induced people to stop and ask for a demonstration. My only purpose for being at this conference was to meet people, and this was good. So, not content with talent night, I brought my didge with me the next day to the conference.

If you have never brought an oversized didge with you to a national conference, you are missing out on a major life experience. People literally stopped me in the parking area outside the hotel, and I obligingly honked on demand. Going to get a coffee – honk on demand. Walking into the lobby – honk on demand. Walk into the exhibit area – honk on demand. NAMI bigwigs, leading doctors, authors, speakers – honk on demand. Patients, family members – honk on demand.

And now you know why NAMI has banned didgeridoos from all their conferences. Ha! But there's still NAMI walks.

The People’s DSM: My Alternative Depression Diagnosis - Part I

If you want anything done right, you have to do it yourself. With the DSM-5 task force and its various work groups and study groups a virtual walking and talking “How many psychiatrists does it take to change a light bulb?” joke, it is time for me to take matters into my own hands.

Following is a very rough draft to the first installment of “The People’s DSM,” which I am dedicating to the pioneering spirit of Robert Spitzer and those who worked with him on the ground-breaking DSM-III of 1980. Spitzer and company essentially ripped up the DSM-II and started over. Something the DSM-5 people should have done to the DSM-IV.

Something I’m doing right now. But I need your help. Please give me your feedback and suggestions and we’ll keep reworking it together till we get it right. On with the show ...

Mood Disorders
Depression

Introduction

The current depression diagnosis, with its antiquated symptom checklist, does not adequately account for extreme variations in emotions, thoughts, and behavior. Below are six domains to depression (such as emotion and thinking), each domain arranged in two complementary pairs, each pair with contrasting characteristics (symptoms or sets of symptoms).

These six domains would replace the symptom checklist.

For the Alternative Depression Diagnosis, clinicians need to check at least one characteristic from each domain. All four characteristics from a particular domain may be checked, even if they are opposite. As opposed to the previous DSM, this is not an exercise in symptom counting. More symptoms do not equate to a more severe depression.

Rather, this is an exercise in spotting symptom (characteristic) patterns and anomalies. Clustering of certain characteristics tends to resolve into one of two types of contrasting depressions: “Vegetative” and “Agitated”. There is also an intermediate “Mixed” depression.

All three may be called depression, but they are likely to demand entirely different and extremely subtle treatment and therapeutic approaches, as if they were different diseases. Current diagnostic practice does not encourage this.

A final note: Suicidal ideation is not included as a characteristic (symptom) here. This will be dealt with in a future installment.

Depressive states (all of the below must be met):

1. Must last most of the day for two weeks or more, with no apparent sign of improvement.
2. Must be a significant departure from baseline condition.
3. Must significantly impair ability to work, relate to others, and enjoy life.

Domains (at least one from each of six):

A. Emotion (Too Much Feeling or Too Little):

1. Subject may feel overwhelmed, and express intense sadness or anger.
2. Subject may experience emotional numbness, such as loss of pleasure, inability to grieve, or feel motivated.
3. Subject may experience excessive guilt or irrationally worry about one’s self or others.
4. Subject may lack the capacity to feel guilt or display concern for one’s self or others.

B. Perception and Sense of Self (Wholly Negative or Some Positives):

1. Subject may experience exaggerated worthlessness, feel deserving of his or her fate, and undeserving of a better personal situation.
2. Subject may experience a sense of exaggerated bad luck, feel undeserving of his or her fate, and deserving of a better personal situation.
3. Subject may view events in a negative light, discount good news, and see one’s personal situation as hopeless.
4. Subject may view events in a temporarily positive light, react to good news, and may see ahead to the possibility of one’s personal situation improving.

C. Thinking (Overthinking or Underthinking):

1. Subject may obsessively ruminate on destructive or self-defeating thoughts.
2. Subject may report difficulty concentrating or trying to plan ahead.
3. Subject may exhibit difficultly in processing routine mental tasks, such as remembering a phone number.
4. Subject may experience anxious or racing thoughts.

D. Behavior (Wholly Passive or Some Active):

1. Subject may experience difficulty engaging in routine tasks (such as keeping appointments or personal hygiene), pleasurable activities (such as hobbies), and relating to others (as if a fish out of water).
2. Subject may engage inappropriately in routine tasks (such as messing up an easy  assignment), pleasurable activities (such as drug or alcohol use or reckless behavior), and relating to others (such as being argumentative and confrontational). 
3. Subject may passively withdraw from social contact and isolate.
4. Subject may aggressively withdraw from social contact and withhold his or her companionship.

E. Mental (Speeded Up or Slowed Down):

1. Subject may experience a deadening of the senses (such as loss of sex drive or inability to taste food).
2. Subject may experience a heightened sensitivity to unpleasant sensations (such as the sound of a person’s voice).
3. Subject may experience a subjective slowing of the brain (such as a feeling of being dead).
4. Subject may experience persistent psychic pain (such as a feeling of wanting to crawl out of one’s skin). 

F. Physical (High or Low):

1. Subject may display nervous energy (such as pacing and inability to sleep or not eating).
2. Subject may display loss of energy (such as psychomotor slowing, fatigue, need to sleep, or overeating).
3. Subject may experience unexplained pain.
4. Subject may feel beyond the ability to feel physical pain.

***

Depressive types

Vegetative depression (subject leans toward most of the following):

Too little emotion, Negative Perception, Tendency to underthink, Passive behavior, Slowed down mental state, and is Physically low. 

Agitated depression (subject leans toward most of the following):

Too much emotion, Some positives in perception, Tends to overthink, Some active behavior, Some speeded up mental states, Some physical heightening.

Mixed depression (subject displays roughly equal vegetative and agitated qualities)

***

Vegetative, agitated, and mixed depressions may bear a relationship. A subject may present first with agitation, as if struggling against his condition, then give in to a vegetative depression. Conversely, an agitated depression may signal progress from a vegetative state toward remission or a worsening of one’s condition.

Final Word (for now)

Replacing the classic symptom checklist helps address some major concerns, namely:

• “Male” traits are mentioned for the first time, such as anger, drug use, confrontation, and aggression (along with “female” traits such as rumination), which should help redress the gender imbalance in the depression diagnosis.
• It helps identify the subject’s predominant state of mind (other than just “depression”), as well as other states, which gives clinicians and patients something to work with.
• It acknowledges the complexity of depression and its infinite variations.

In addition, the vegetated/agitated distinction eliminates the current and confusing melancholic/atypical depression distinction. It also accounts for the “pleomorphic” nature of depression, where symptoms (characteristics) may present differently from depression to depression or even within the same depression.

Two important first principles: No two depressions are alike. Depressions cannot be treated as if they are all the same. The current DSM discourages both clinicians and patients from thinking this way. The People’s DSM is offered as an antidote to this practice.

***

This is a lot more to come to my alternative depression diagnosis, including chronicity, cycling, severity, dimensional concerns (such as anxiety, mania and temperament), suicidality, and relationship to stress. Stay tuned. In the meantime, your feedback is strongly encouraged. Fire away ...

Illness or Personality - What's in YOUR Depression?

Both here at Knowledge is Necessity and over at HealthCentral’s BipolarConnect, I have been investigating the issue of illness vs personality (or temperament). Say you are dealing with depression. In all likelihood, you are thinking that your depression is an alien invader that is robbing you of your personality. But what if miserable is your true baseline?

Why this is important is that medications are designed to treat an illness, not change a personality. An article by some prominent academics on the blog site of author Todd Finnerty PsyD makes a case for the diagnosis of Depressive Personality Disorder (DPD). I had occasion to hear one of the authors, Michael Bagby MD of the University of Toronto, at the 2006 American Psychiatric Association annual meeting in Toronto.

Historically, according to Dr Bagby, minor depression was thought to exist on a spectrum with personality, and "may define a group who are pessimistic, disaffected, and frustrated, perhaps because they see their illness as an intractable and enduring part of their selves."

According to the authors of the blog article: “Depressive personality disorder is not simply a variation of normal psychological functioning.” It is an illness, distinct from major depression and dysthymia.

Appendix B to the DSM-IV lists DPD as “worthy of further study,” but is not included in the main text. The appendix defines DPD as “a pervasive pattern of depressive cognitions and behaviors.” By contrast, classic Axis I DSM major depression is described as an “episode,” with symptoms lasting at least two weeks, while minor depression (dysthymia) is regarded as “chronic” (two years or more).

In other words, if you are undergoing major or minor clinical depression right now, all those around you - including your psychiatrist - assume your brain will eventually boot back up to “normal.” But with DPD, you may already be imprisoned in your own version of “normal.”

According to the authors of the article, a number of studies validate DPD, but the obvious overlap with clinical depression, in particular dysthymia, poses major problems. The authors argue that it is dysthymia that suffers from redundancy, not DPD. DSM dysthymia, they contend, comes across as major depression lite, with nearly the same symptoms but with an arbitrarily-added two-year requirement.

DPD, by contrast, serves up a different symptom list, namely:

1. Usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness
2. Self-concept centers around beliefs of inadequacy, worthlessness, and low self-esteem
3. Is critical, blaming, and derogatory toward self
4. Is brooding and given to worry
5. Is negativistic (passive-aggressive), critical, and judgmental towards others
6. Is pessimistic
7. Is prone to feeling guilty or remorseful
   

But the real turf DPD may be encroaching on may involve the personality disorders (such as avoidant personality disorder). In particular, there are issues regarding the Five Factor Model (FFM), which is to personality testing what Simon is to American Idol.

The FFM has a good chance of influencing the next DSM as part of a “hybrid” system of classifying Axis II personality disorders. The current DSM is structured according to the type of “categorical” schema that works (to a point) for Axis I disorders. In other words, depression is different from schizophrenia. (Never mind that depressed people can have psychosis and those with schizophrenia can be depressed - that is for another piece.)

This separation is even more problematic with personality disorders, where there is considerably greater overlap amongst symptoms (such as where borderline meets antisocial meets narcissism). A “dimensional” schema not only acknowledges the overlap, but takes into account degrees of severity. As a speaker explained at a conference I attended a few years back: We all have blood pressure. But we have reliable tests to ascertain when our blood pressure is too high.

Think of the FFM as a blood pressure test. The “big five” traits it measures include openness, conscientiousness, extraversion, agreeableness, and neuroticism. A person who passes with flying colors is one who is not likely cave into fear, has his or her shit together, lights up a room, cares about others, and doesn’t readily fly off the handle.

If you were to see these qualities in someone on eHarmony, you would immediately propose marriage to this individual, sight unseen. If for some reason, you failed to initiate contact, you are probably emotionally tied up in knots.

The FFM may crack your case, but here’s the rub. Suppose the results revealed a “neurotic” temperament. According to the authors of the blog article, neuroticism is a pretty airy-fairy term that also embraces other emotions such as anger and anxiety.

It could be you fail to pursue an eHarmony lead because your inner critic is working overtime. You consider yourself worthless. You’re beating yourself up. And now you’re alone and socially isolated. How does that make you feel? Well, depressed.

Okay, suppose you do have a depressive temperament. Does that mean you have DPD? Absolutely not. The authors of the article point out that DPD has a dimensional component, which means we are asking “how much?” So, if you’re the type who prefers staying home alone with a book to going out dancing, you can relax. You may be a lot happier and better adjusted than Joe Cool and Miss Congeniality.

But even if you have been thinking that black is the new pink your entire life, the experts remind us that although our traits are inherited they are not necessarily deterministic. Turning our lives around may not be easy, but we can change, or at least come up with adaptive responses.

The authors contend that DPD should be included in the DSM-V, under personality disorders. We will leave that debate for another time. The point is, in the unending quest for the true me we alone are our own judges. Illness or personality? Perhaps a bit of both? We can’t afford to wait for someone else to ask these questions.

Further reading:

From Knowledge is Necessity

Is There Anything At All Possibly Good About Depression?
Depressed or Thinking Deep?
Breaking Down Personality

From BipolarConnect

Wearing the Mask, Acting "Normal"
Peace of Mind
Personality vs Illness - The Conversation Continues
Personality or Illness

My Friend Kevin - Looking Back

The end of the year is both a time of looking back and looking ahead. So it is that I am reflecting on my friend Kevin Greim, who, on a miserable muggy New Jersey morning in September, 2008, threw himself in front of a train. He was 28.

Five years ago, I was facilitating a DBSA support group in Princeton, NJ. In walked Kevin, exuding a goofy charm, baseball cap on backward. But there was something about his presence that indicated he was no mere goofball. The others in the room felt it, too.

As we grew closer, he began opening up to me. Kevin was a Jehovah’s Witness. It was a faith he had arrived at rather one he was born into. As he explained to me and others, his faith provided handrails. His life now had purpose, direction. His ultimate goal was to do full-time missionary work.

But he had his setbacks, his dark moments. And his illness, his illness ...

I recall a long conversation with him over coffee, in which he recounted to me a number of difficulties he was dealing with on the missionary path.

Life as a missionary wasn’t meant to be easy, I responded sympathetically, especially if you are God’s chosen. I paraphrased a key passage from Second Corinthians for him as best as I could:

"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."

Paul was on a mission, literally a mission from God. His first two Letters - Romans and First Corinthians - reflect the optimism of one with God on his side: confident, bossy, out to change the world.

Second Corinthians, written many years later, reflects a different Paul: weary and disenchanted, struggling to keep his faith. Acts of the Apostles reports Paul being set upon and left for dead by a mob in Antioch and at the mercy of another in Ephesus.

My take, as I related to Kevin went like this: Here’s God telling Paul in effect, “You presume to act in My name, well then ... let's see how sincere you are after a mob has tried to crack open your skull, you find yourself holding on for dear life to a piece of boat in the open sea, your friends have turned on you, your followers have abandoned you, and your love is returned in endless measure with unbridled hate.”

It's not in God's nature to make things easy, I went on to tell Kevin. You want an easy life, then do something easy. You want to accomplish something, well don't expect any breaks. The nature of things is that you will be tested.

Of all things, my bleak little homily had the effect of cheering Kevin up. I think my friend felt that he alone was responsible for his own difficulties. Having his mettle tested by God was an entirely different proposition.

Kevin, in turn, told me something I did not know: In Nazi Germany and elsewhere in Europe, the Witnesses stood up to Hitler. At great risk to their own personal freedom and safety, they befriended Jews, they patronized Jewish businesses. Ultimately, 12,000 were sent to the camps, where 2,000 died. A purple triangle on their prison garb identified them by their religion.

I thought of other faiths that had virtually rolled over and played dead for Hitler. These Witnesses had guts, I could only think. 

Kevin is gone. But today, thanks to my friend, you are reading something positive about Jehovah’s Witnesses, perhaps for the first time in your life. I like to think that Kevin succeeded in his mission.

Rerun - Philosophy: Because We're Mindless Without It

A blast from the past from March. Enjoy ...

Check out the image on the top right. I can think of no better way to illustrate what this blog, "Knowledge is Necessity," is all about. The guy pointing to the sky is Plato, the one with his palm facing the ground is Aristotle.

The two form part of a much larger painting by Raphael - his masterpiece - entitled "The School of Athens." The canvas portrays more than twenty identifiable Greek philosophers - as well as a bunch of unidentifiable ones - clumped in small groups engaged in enlightened discourse.

What's so important about philosophy? Last year, I happened to catch the first three or four episodes in a 60-lecture video series, entitled, "Great Ideas In Philosophy." Oxford scholar and Georgetown professor-emeritus Daniel Robinson PhD explained that something extraordinary happened in ancient Greece.

Prior to Greek philosophy, Professor Robinson pointed out, thinking was essentially religious. Entire cultures were organized around the principle of encouraging everyone to think the same. No one questioned handed-down beliefs.

What the Greeks did essentially changed everything. Socrates and others urged their followers to think for themselves, to take nothing for granted, to challenge everything. In the face of Socrates' withering inquisitions, lazy thinking didn't stand a chance. Athens, it appears, wasn't quite ready for this, and Socrates paid in full measure.

His student, Plato, managed to die in bed, as did Plato's student Aristotle. Without them, our frontal lobes would have nothing to do. Not only did they turn thinking into a profession, they gave us the tools to think. The world was never the same.

Every field of human enquiry bears their indelible stamp: Science, government, the arts, human nature ...

Even religion. The way we appreciate Jesus is through the intellectual framework built by Plato and Aristotle. "The School of Athens" hangs in the Vatican.

The image that illustrates today's blog post is Diogenes. You might refer to Diogenes as the anti-philosopher. When Plato described man as a "featherless biped," Diogenes handed him a plucked chicken.

In Raphael's painting, Diogenes is seated alone, as if shunned by the others. Diogenes serves as a forceful reminder that even today's bold free-thinking is tomorrow's mind-crushing orthodoxy. This tends to happen when we organize our connected thoughts into schools of thought.

The antidote is to be our own philosopher. We learn, then challenge everything we learn. Then we relearn.

Knowledge is necessity, but knowledge is also elusive. It is something we strive for, rather than possess. If someone claims to have it, and offers you a piece of it - stop, think. What would Socrates do?

Me, Apollo 15, and the Future

The following is a continuation of Me, Captain Ahab, and the Anterior Cingulate Cortex:

The year - 1971. Location - the moon. After 23 hours with no sleep, Apollo 15’s two moonwalkers were back in their command module in lunar orbit, preparing for their return home. Back in Houston 240,000 miles away, ground controllers picked up anomalous EKG readings from one of the astronauts. Jim Irwin’s heart was skipping a beat, then beating twice rapidly. After communicating with Irwin, the flight surgeon at Mission Control diagnosed a specific type of heart arrhythmia known as bigeminy.

Had Irwin been on the ground, doctors would have treated him for heart attack. But it turned out that the command module, with a 100 percent oxygen atmosphere and zero gravity, was better than any ICU he would have been placed in on earth. His heart soon settled back to normal, and Apollo 15 later successfully splashed down without incident. A few months later, Irwin had a heart attack. Twenty years later, yet another heart attack killed him.

Fast forward to the present. Location - earth. An individual very close to me was admitted to a psychiatric unit, and, after careful evaluation, was diagnosed with depression and given an antidepressant. Following a second hospitalization, he was put on different meds and released. Soon after, he was back in the hospital.

Basically, this individual has broken brain disease, and if we knew exactly what part of the brain was broken and could link the malfunction to the symptoms he was experiencing, we would have an exact term for it and perhaps have a clue of how to best treat it. But diagnostic psychiatry in 2009 is no match for the diagnostic cardiology of 1971 - at least not right now it isn’t.

Part of what is holding us back is that mental illness is far more complex than cardiac illness. What brain scans are showing is something akin to a total system collapse in the brain, involving many interconnected brain regions, rather than a specific fault. The brain science is beginning to tease out subtle structural and functional distinctions across a range of diagnoses. But this is hardly equivalent to taking an X-ray, finding a bone fracture, and knowing exactly how to set the break.

Nevertheless, brain scans are providing us with a sneak preview of the future. In a famous set of experiments performed two or so decades ago, OCD subjects (ones obsessed with cleanliness) shared a brain scan machine with a "dirty" sweat sock. Their respective brain loops lit up like a Christmas tree. When exposed to a "clean" sock, their brains quieted down.

The anterior cingulate cortex (ACC), part of the mid-brain, contains specialized neurons responsible for “gating.” which allows the brain to focus on certain incoming information (such as a conversation) while tuning out others (such as the background hum of an air conditioner). When things go wrong in the ACC, all manner of bad things can happen, such as OCD or schizophrenia or depression.

Thanks to this knowledge, doctors were able to adapt deep brain stimulation (DBS), used for Parkinsons, to experimental (and still extremely rare) psychiatric surgery. In Feb this year, the FDA approved DBS as a last resort treatment for OCD. The procedure also shows promise for depression. In DBS, a metal lead is inserted through folds in the brain. An electric pulse breaks up neuronal signals (such as those responsible for distracting thoughts and ruminations) in the ACC region. Unlike earlier generations of brain surgery (such as cingulotomies) no surgical lesions are involved. The surgery is reversible, but does involve risk.

Let’s be clear on this: This is not a piece extolling the virtues of psychiatric brain surgery. Indeed, it is difficult to imagine psychiatry headed in this direction. But what we are witnessing nonetheless presents us with a tantalizing peak at what tomorrow may involve, namely:

It is foreseeable that advances in technology will make MRI machines, or some other brain scan technology, convenient and affordable and routine, equating to advances in computer technology.

In the meantime, we already have the means to do gene scans - the chips are getting faster every year. Now imagine the software to interpret data coming from a whole ranges of sources - gene scans, brain scans, psychiatric evaluation, neurological testing, etc - to give the treating psychiatrist a range of options to consider.

The following is wild speculation: Keep in mind that the dominant operating paradigm for mental illness is system breakdown, a host of things going wrong seemingly all at once. But suppose we could get a bit closer to the source - say the hippocampus (involved in memory) failing to boot up, say key parts of the frontal lobes going off-line, say certain stress pathways overloading. Say we were able to pinpoint various signaling bottlenecks and hubs.

Thus, depression is no longer just depression. In fact, once we get a true read on what is going on, we may call its manifold variations something entirely different. All this would suggest targeted treatments and therapies, even with today’s highly imperfect remedies. Perhaps a dopamine enhancer to kickstart a certain brain system rather than an SSRI. Perhaps talking therapy focusing on past trauma rather than directed at here and now challenges.

The long-term pay-off would be that this kind of knowledge would spur future drug development (namely smart meds) and further refine talking therapies. It could also open the way for pinpoint electrical therapies and who knows what.

Private investors would need to see the solid science - a clear idea of how to get from A to B to C - before they were willing to put their money on the line. The catch is this type of science is dependent on the public sector. Basic research into mental illness is notoriously underfunded as it is. For lack of will, then, we may be unable to see our way to the future, much less realize it. The Apollo program was supposed to signal the beginning of manned space exploration. We haven’t been back to the moon since 1972, nor do we have the rockets for it.

The future - so near, yet so far ...

Robert Spitzer and the DSM - Part III

In Part I, I talked about finding myself at a dinner table at a symposium at the 2003 APA annual meeting with Robert Spitzer, who masterminded the ground-breaking DSM-III of 1980. Part II touched on the history of the conflict between diagnostic and Freudian psychiatry, and the triumph of Spitzer’s DSM-III. To continue ...

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. And here I was looking up from my salad trying to think of something to say.

Out of deference, I waited for the psychiatrists at the table to open the conversation. I would just be a fly on the wall. But no one spoke. Silence. Just the clinking of glasses and the rattling of plates. I always knew psychiatrists were a bit weird, but this was ridiculous.

I introduced myself to Dr Spitzer as a bipolar patient who was at this particular conference as a journalist. These days, I simply introduce myself as a journalist. Back then, I over-identified with being an entry in Spitzer’s diagnostic schema.

Let’s put it this way, if you are in a constant life-and-death struggle with testicular cancer you are understandably thinking about it every second of your life. But then comes a time when you need to forget that you have one testicle and start focusing on your own personal Tour de Life.

But, yes, I still wear a yellow and blue DBSA rubber wristband, not unlike the yellow cancer band that Lance Armstrong made famous.

Anyway, I had a few thoughts of my own about the DSM, I told Dr Spitzer. Would he be interested in hearing them?

This is like telling Einstein that I had a few thoughts about relativity, but Dr Spitzer indicated that I proceed.

What motivated me to ask in the first place was that I naively assumed that the very last person to regard the DSM to be cast in stone would be the person who broke the mold in the first place. Think of Robert Spitzer as the great auto designer Harley Earl, and the DSM-III of 1980 as the 1955 Chevy and the DSM-III-R of 1987 as the 1957 Chevy.

By contrast, the post-Spitzer era - the DSM-IV of 1994 and the DSM IV-TR of 2000 - merely played around with the fins. So now, here we were in a new millennium driving around to the mechanics of a bygone era

Mind you, at the time I lacked the both the standing and the knowledge to challenge Spitzer on this, so I decided to stick to the one aspect of the DSM that I had put some thought into. This concerned the issue of gender and depression. Here, I was on fairly solid ground, as many experts were pushing for changes to the DSM on this matter. My view, and the view of these experts, is that the DSM symptom list is biased toward picking up depression in women while men suffer in silence. According to conventional wisdom, twice as many women experience depression as men. But a bit of tweaking to that symptom list, I argued, could even out that equation.

I waited for the go-ahead, then proceeded down the list. Symptom one is “depressed mood most of the day,” and the unfortunate example is “appears tearful.” Men, by contrast, express themselves in other ways or else fail to express themselves at all. Number three concerns weight gain or loss. Think of what women go to the fridge for when feeling low. Now think of what men reach for. Symptom seven is about worthlessness and guilt, but men tend to lash out and blame others. Last but not least is suicidal thinking. Men fall victim more often than women, but women make far more attempts, and so are more likely to come to the attention of the profession and be treated.

Dr Spitzer pondered my comments, then, as psychiatrists are wont to do, said nothing. By now, the main course had come out. Any further conversation was light and inconsequential. Soon the first of several speakers started talking. It was time to go to work, to take notes.

Two hours later, the last of the speakers wrapped up. Question time was just ahead. Most members of the audience use this brief interval to leave, and so it was that Dr Spitzer got up to make his exit, but not before addressing me.

“I thought about what you said,” he told me, or words to that effect. And then his verdict: “And I don’t go along with any of it.”

Then he rose from his chair and was gone.

Hey, what did I know? He was Robert Spitzer, founder of modern psychiatry. I was just a male bipolar patient who had to deal with depression every day of my life.