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 ...

Akiskal Unplugged, Part III - A Dying Breed

My last two pieces have discussed issues relating to a talk presented by Hagop Akiskal of UCSD to DBSA San Diego on Monday this week. As I commented in my first piece:

Basically, if you want to know about bipolar, you read the usual literature. If you want to know what is really going on, you read Akiskal (and Frederick Goodwin, and Robert Post and a few others).

Akiskal’s thinking is light-years ahead of just about all of his colleagues, but there is something very old-school to his approach. Like his hero Emil Kraepelin, Dr Akiskal’s insights are based on countless zillions of hours of exceptionally meticulous clinical observation. Yes, a PubMed search reveals 400 published articles to his name, but all are informed by a lifetime of listening to actual patients.

Listen - who has time for that any more? In a comment to my first piece, Louise observed that “doctors like Akiskal and Goodwin are a dying breed.” She pointed me to an article in the NY Times that came out the day before Akiskal’s talk. The article makes official what we have known for years. According to the piece, discussing the dilemma of PA psychiatrist Donald Leven, who first started practicing in 1972:

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

According to Dr Levin: “I miss the mystery and intrigue of psychotherapy. Now I feel like a good Volkswagen mechanic.”

Actually, it’s a lot worse than that. At least good old-fashioned VW mechanics knew how to tear apart and put back together the whole car. In today’s scary new world of faux-psychiatry where insurance companies call all the shots, Dr Levin is more like the guy who performs oil changes at Jiffy Lube.

All that wealth of experience - wasted.

Perhaps you can see where I’m going with this. If psychiatrists no longer have time to listen to their patients and carefully observe, where are their insights going to come from?

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

Psychiatry these days is a by-the-book exercise, and the book is wrong.

Eventually, all our new understanding of the science of the mind will come from brain science and genetic research. But two years ago I heard leading schizophrenia researcher David Braff at a conference caution against the devaluation of clinical experience. Basically, the lab hotshots require the insightful observers of reality tell them where to look and what to look for.

Indeed, Dr Akiskal has been doing that for years. In his talk on Monday, Akiskal made reference to his collaboration with psychiatric geneticist John Kelsoe of UCSD. Essentially, instead of searching for elusive bipolar genes, Akiskal pointed Kelsoe in the direction of genes that influence affective temperament, which promises to be a more fruitful exercise.

Trust me, a geneticist would never have thought of that on his own.

But with a new generation of psychiatrists performing lube jobs, with academic researchers not seeing patients, where are the clinical insights going to come from?

As Louise said, Akiskal and Goodwin - not to mention their generation - are a dying breed. When they go, there will be no one to replace them.

Akiskal Unplugged, Part II - Temperament

To continue where we left off ...

The subject of temperament came up in passing in Hagop Akiskal’s talk to DBSA San Diego that I attended on Monday evening. Temperament is very central to Akiskalology and the art of understanding what is really going on with our moods. Unfortunately, Dr Akiskal’s audience got too involved interrupting his presentation for generic Ask-the-doctor questions for him to string together two sentences in a row on the topic.

This is not a criticism of those who turned up on Monday. The party line that gets drummed into our heads by lesser minds tends to blind us to the thinkers and the visionaries in our midst, and I plead guilty on serial counts to this. Let me rewind the clock to spring, 2002:

I was in Philadelphia attending my very first American Psychiatric Association annual meeting. Twenty thousand psychiatrists and industry hacks (it’s often hard to tell the difference) were in town for the six-day extravaganza. Biological psychiatry was singing high praises to itself. New meds were coming on the market and the best brains in the business were figuring out smarter ways to use the current ones. Even the highly critical commentary supported the basic paradigm - namely that there was a pharmaceutical answer for just about everything that went wrong beneath the hood. Even if we didn’t yet have all the answers, they were well within our reach.

So it was that I entered a dark and crowded room to hear Dr Akiskal for the very first time. Although I was familiar with the name, I only had the barest superficial knowledge of his work. I had been expecting him to elaborate on why some forms of depression should be regarded as bipolar, when a bunch of “It’s Greek to me” stuff came up on his PowerPoint.

Literally. Up went slides of the Greek four humors (or temperaments), such as “melancholia” (literally meaning black bile).

What did this have to do with psychiatry? was my first reaction. Then again, I rationalized, Akiskal was probably just setting the scene. It’s a recurring problem with medical doctors who probably took arts courses in their undergraduate years. But then he started elaborating on the four humors. Not only that, he came up with his own version of the four humors. And not only that, he came up with evolutionary reasons for the four humors.

Okay, this has gone far enough, I thought. Enough, already, with this rambling prelude on ancient history. Let’s cut to the fugue. I’m here to find out about depression and bipolar. I won’t say I was disappointed. Rather, I was confused, like listening to a difficult piece of music for the first time. I had a lot of stuff to report from that first APA meeting, but Akiskal’s presentation wasn’t one of them.

Such are the pitfalls to being deaf-dumb-and-blind to the thinkers and visionaries in our midst.

So here is what Akiskal went into in depth talking to psychiatrists in Philadelphia in 2002 and that he touched on talking to patients and family members two days ago in San Diego:

By temperament, Akiskal is referring to heritable “stable behavior traits with strong affective coloring,” throughout life. Thus, downbeat may be your baseline personality “trait”, which is a very different proposition than being in a temporarily depressed “state,” but the two are related. So much so that understanding how this state-trait dynamic works for us is crucial - absolutely crucial - to our wellness.

Drawing upon the work of the German psychiatrist Ernst Kretschmer writing in the 1930s, Akiskal points out that temperament and various related personality constructs may not only set us up for mood disorders, but can be considered as sharing the same continuum, from healthy to extreme (though much more research is needed to bear this out).

And, of course, wherever you find Akiskal, you find Kraepelin. As Akiskal describes it in a 2010 article:

The concept that different kinds of temperament are constitutionally based types of behavior can be traced back to the ancient humoral theory of Hippocrates. About 90 years ago, Kraepelin described four basic affective dispositions (depressive, manic, cyclothymic and irritable), which he believed to be subclinical forms and many times the precursors of major affective psychoses.

Moreover, these temperaments can be found in the blood relatives of those with manic-depression (which would include recurrent depression as well as bipolar). Indeed, as Akiskal pointed out two nights ago, it’s the relatives of bipolar patients who tend to benefit from having bipolar characteristics (namely in a genetically dilute form), not necessarily the patients (who unfortunately get hit with the illness full strength). Indeed, relatives and bipolar IIs are more likely to have creative accomplishments (borne out in surveys he has conducted) rather than those with bipolar I, who have far too much to contend with.

In Philadelphia, Akiskal substituted “hyperthymic” temperament for “manic,” and these are the ones who obviously benefit from having a “little bit” of bipolar. These are your exuberant upbeat types, highly energetic and super-confident, out to conquer the world. Hyperthymic is the “trait.” By contrast, “hypomanic” is the “state.”

To very loosely translate Akiskal, imagine two individuals giving very dazzling presentations in a large room. One is on the way to a brilliant career. The other is headed for a crash. Same behavior, very different result. The naturally upbeat individual will power on through thick and thin, and be abundantly rewarded. The temporarily upbeat individual is living on borrowed time.

But it’s much more complicated than that. Even hyperthymic individuals can go over the top (just ask Monica Lewinsky’s erstwhile boyfriend). And hyperthymia overlayed with a depressive state is playing with fire.

Confused? So was I back in Philadelphia in 2002.

Much more to come ...

Akiskal Unplugged

Hagop Akiskal of UCSD is bipolar’s ultimate insider-outsider, at once the field’s elder statesman and enfant terrible, the best-known name in an establishment that would often rather not know him, and vice-versa. “I have no use for the DSM,” he told me as I greeted him last evening at a talk he was about to deliver to the San Diego chapter of DBSA.

And he was only just getting warmed up.

Dr Akiskal’s presentation was more in the nature of a conversation, with revealing tangents that allowed his audience rare glimpses into the mind of a visionary-at-work. A lot of what you read here on "Knowledge is Necessity" is highly derivative of Akiskal, and for good reason. Basically, if you want to know about bipolar, you read the usual literature. If you want to know what is really going on, you read Akiskal (and Frederick Goodwin, and Robert Post and a few others).

“Most depressions are at some level bipolar,” Dr Akiskal told his audience. Akiskal literally owns the terms “bipolar spectrum” and “mood spectrum,” which view both mood and temperament as blended shades of the same phenomenon rather than separate entities. Thus depression typically has elements of mania or hypomania, and vice-versa. Agitated depressions, if you like, or dysphoric manias. Think road rage, even if you don’t drive.

Just to make things interesting: Imagine if you have an upbeat (what Akiskal calls “hyperthymic”) temperament. You get depressed - “state,” in effect, superimposed over “trait.” It doesn’t take a rocket scientist to realize that your depression is likely to look quite a bit different than that of the melancholic type sitting next to you. But until Akiskal arrived on the scene no one in psychiatry even came close to thinking this way.

Okay, maybe Emil Kraepelin, a name Akiskal drops every chance he gets, including at least three or four times last night. Kraepelin, who was born the same year as Freud, coined the term, “manic-depression.” What Kraepelin meant by manic-depression embraced recurrent depression as well as bipolar. The DSM-III of 1980 missed this completely, as did the DSM-III-R of 1987 as did the DSM-IV of 1994 as did the DSM-5 (due out in 2013).

See why Akiskal has no use for the DSM?

“They are spending millions of dollars on the DSM-5,” Akiskal thundered. “I refuse to be part of it.” The DSM, he says, lists “five hundred ways to lose your sanity.” It could be simplified, he said, to about five or ten or fifteen.

“I don’t believe in borderline,” he threw in for good measure.

Ah, vintage Akiskal.

Much more to come ...

***
More Akiskal on mcmanweb:

The Mood Spectrum
Multipolar Depression
The Fear and Anger Equation