Hitler on the Couch

As I promised last week, a study on Hitler. My starting point was Nassir Ghaemi’s recent “A First-Rate Madness,” which raised the extraordinary proposition that Hitler was far more “normal” than we give him credit for. What Ghaemi was driving at was that evil is not the exclusive domain of people with twisted minds. Perfectly normal individuals are as capable of gross inhumanities, or for that matter being royal pains in the ass.

In a piece in August, Reckoning with Evil, I laid out Ghaemi’s position, namely that until 1937 Hitler’s bipolar (his depressions and manias are well-documented) “seemed manageable.” Moreover, his hypomania appeared to benefit him in a way that influenced his rise to power, “fueling his charisma, his resilience, and political creativity.”

Then a quack physician put him on a cocktail of amphetamines and barbiturates that turned him into a raving maniac. Next thing, he was invading Poland. By 1943, he was receiving multiple daily injections, totally out of touch with reality, and was impossible to get along with.

Ghaemi’s analysis begged an alternative viewpoint, which sent me to Barbara Oakley’s “Evil Genes: Why Rome Fell, Hitler Rose, Enron Failed and My Sister Stole My Mother's Boyfriend.” As I reported in five previous pieces, Dr Oakley sees “borderpath” tendencies as the driving force of Machiavellian personalities, what she terms as the “successfully sinister.” Thus, a supreme Machiavellian such as Chairman Mao - responsible for more than 70 million deaths - deployed a vast range of psycho/sociopath, borderline, narcissistic, and paranoid traits to his considerable advantage, managing to die in bed at age 82, venerated as a God-figure.

Dr Oakley sees Hitler cut from similar cloth. Her main source is an OSS analysis prepared by a leading Freudian psychoanalyst, Walter Langer, during World War II. Dr Langer’s research was exhaustive, totaling 11,000 pages, and from this he created a criminal profile that is still regarded as authoritative.

Dr Langer characterizes Hitler as a “neurotic psychopath.” Ghaemi in a footnote takes issue with this diagnosis (his only reference to Langer), though it is clear the label is only a starting point. A quick Google search turned up an excellent piece, Getting Inside Hitler’s Head, by military journalist Brian John Murphy, and it is instructive to go off his account ...

As a child, Hitler learned how to manipulate his mother by staging temper tantrums until she caved in. Hitler carried over the same behavior into adulthood. His screaming raging fits were the stuff of legend, and throughout his career he was able to deploy these outbursts to his advantage. His public speeches - an extreme departure from standard German oratory - can be viewed as scripted tantrums that bent the masses to his will.

His father’s death at age 12 appeared to have a lot to do with turning him into an angry young man. Soon after, his performance in school plummeted and later he dropped out. As a down-and-out young man in Vienna, he became a rabid anti-Semite and extreme pan-Germanic xenophobe, unfortunately very “normal” for the time. Soon he found his calling in the trenches on the Western Front.

Hitler’s taste for war may have resulted in two Iron Crosses, but it also completely spooked his superiors, who vowed never to make him an officer. He failed to bond with his fellow soldiers, and avoided women. His later associations with women were characterized by sexual deviances and callous behavior. Six of his former lady friends attempted suicide. Two succeeded.

After the war, Hitler’s bitterness over Germany apparently being sold out by traitors fit right in with the sentiment of the day. In no time, he hit his stride as a political rabble-rouser, deploying his strange charisma, bitter misanthropy, and inexhaustible energy to stunning effect. Along the way, he spied on his socialist-leaning comrades-in-arms in the trenches, and succeeded in getting some of them hanged.

Exhibit A in Hitler’s psychopathy, of course, is Mein Kampf, written in prison following a failed populist uprising where he fired a pistol inside a beer hall. There his pathology is revealed in his own words, not to mention his demented thinking regarding Jews and other non-Aryans. It’s all there, except the “final solution,” and that can easily be inferred. By the time Hitler completed his blood-stained ascendance to total power as Chancellor in 1933, there was nothing standing in the way. That same year, he spoke with his military leaders about “conquest for Lebensraum” (interpretation: invading Poland). At his first cabinet meeting that year, he prioritized military spending.

Thus, by the time Hitler invaded Poland in 1939, he had a massive and well-equipped army and air force at his disposal, which he had already deployed beginning in 1936 to re-occupy the Rhineland and in support of Franco in the Spanish Civil War, plus to annex Austria and a piece of Czechoslovakia.

According to Murphy’s piece:

The Hitler Langer profiled was a man with a boundlessly grandiose concept of himself. Langer said Hitler believed fate set him apart as a superman, a chosen one, the messiah of a future German empire, who was infallible except for when he had engaged in what he called “the Jewish Christ-creed with its effeminate pity-ethics.” When crossed, Hitler wanted retribution that was godlike in its devastation.

Dr Oakley in “Evil Genes” pays considerable attention to delusional thinking, a trait common amongst conspiracy theorists, who are capable of maintaining their crackpot beliefs with great conviction in complete defiance of the facts. Hitler, needless to say, could always rationalize as legitimate his every action, no matter how bizarre and contrary to human nature.

Murphy notes that Langer’s analysis was made without reference to Hitler’s massive methamphetamine consumption, which only came to light after World War II. Clearly, Hitler’s drug cocktail greatly worsened his pathology. According to Murphy:

Witnesses describe the 56-year-old Hitler in 1945 as a shuffling old man wearing a uniform spotted with food and grasping for a handhold every few steps. His left hand trembled violently. Cake crumbs clung to the corners of his mouth. The bags under his eyes were swollen and dark. He drooled. ... By April 1945 he had little left physically or mentally.

So, did Hitler’s quack physician light “a fuse that exploded the entire world,” as Ghaemi maintains, or would Hitler have invaded Poland, anyway? Suppose he had been able to push ahead with his irrational ambitions, but in a far more rational and drug-free state of mind? Would the Nazis have actually won the Second World War?

Very scary thought.

Lincoln and Depressive Realism

The following is my fifth installment in our conversation on Nassir Ghaemi’s “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness.” Chronically normal may be an indulgence we can afford when the country is running on autopilot, Ghaemi tells us in so many words. A national crisis is an entirely different proposition.

"I am now the most miserable man living," the 31-year-old Lincoln famously confessed. "Whether I shall ever be better I can not tell; I awfully forebode I shall not; To remain as I am is impossible; I must die or be better."

Among other things, Dr Ghaemi credits Lincoln (and Churchill and others) with depressive realism, ie the ability to size up people and events as they are, not as we wish them to be. This is much the same point raised in Joshua Shenk’s outstanding 2005 book, “Lincoln’s Melancholy: How Depression Challenged a President and Fueled His Greatness.” Significantly, Shenk’s main psychiatric authority was none other than Ghaemi. Likewise, Ghaemi’s analysis of Lincoln draws largely from Shenk.

Here is where Shenk is coming from:

“Other forces were also at work,” I wrote in a review on mcmanweb. “Depression turned [Lincoln] into a hard-headed realist, untainted by the pitfalls of misguided optimism. His uncanny melancholic third eye allowed him to think like a visionary. ...”

Thus, when the Kansas-Nebraska Act of 1854 and the Dred Scott decision of 1857 led to the prospect of legalized slavery in the northern states, Lincoln found his voice. As I noted in my review:

Lincoln’s melancholia allowed him to see events with preternatural second sight. Southerners with a vested interest in the outcome stood a clear chance of having their way over largely indifferent northerners. It was the thin edge of the wedge that could put an end to free labor markets everywhere and dash the dreams of the Founding Fathers. The clock was being rewound back to the Dark Ages, and Lincoln was not confident of his ability to put a stop to it. Nevertheless, he felt compelled to speak out against the madness, even at the risk of his career.

Paradoxically, his political career took off, though true to melancholic form he saw every slight setback as a major failure.

By the time Lincoln was sworn in as President, seven southern states had bolted from the Union, with the border states threatening to join the South. In the early going, the North lost far more battles than it won, and as the terrible carnage mounted much of the population lost its resolve, leaving Lincoln with threatened rebellion on the home front.

This was not a time for cock-eyed optimists, Ghaemi lets us know. There are people still alive who recall Neville Chamberlain’s infamous declaration of “peace in our time.” Citing a landmark study by Ellen Langer and Jane Roth and a lifetime of work by Shelley Taylor, Ghaemi refers to  an unfortunate tendency in the cloyingly normal toward “an illusory sense of control, especially if things seem to go well for them.”

There is even a term for it - “positive illusions.”  As Ghaemi puts it: “We tend to see mental health as ‘being normal’ - happy, unrealistic, fulfilled. Yet Taylor showed that we sacrifice realism in the interest of happiness.”

Thus, as late as 1938 Chamberlain convinced himself that Hitler “could be relied upon to give his word.” All of England - with one notable exception - was similarly deluded. The only realistic thinker of the day was a loose cannon politician marking time in the political wilderness with his legendary “black dog.”

Lest we confuse depressive realism with the ability to wage war, Ghaemi reminds us that our greatest proponents of peace - Gandhi, Martin Luther King - also possessed this same seeming clairvoyance. In Lincoln, waging war was his last option, after every attempt at peace had failed.

A lifetime of depression. Ghaemi contends, also conferred upon Lincoln the gift of empathy (the topic of a future post), which often had to be sacrificed in pursuit of a brutally realist agenda. Thus, early in his Presidency, with the war going against the Union and his own political support rapidly eroding, Lincoln gave the cold shoulder to a black delegation, prompting Frederick Douglas to issue a scathing attack.

When the time was right, however, Lincoln seized the moment and Douglas became one of his greatest supporters. As I noted in reference to Shenk’s work:

The [Emancipation Proclamation] risked alienating the border states, but would serve to give the war a higher moral purpose. Nevertheless, Lincoln entertained no delusions about whose side God was on. Death had visited far too many northern households for him to believe that the Almighty was playing favorites. "My greatest concern is to be on God's side," he advised a colleague.

Later, in his second inaugural address, Lincoln would confess: “Both read the same Bible and pray to the same God, and each invokes His aid against the other ... The prayers of both could not be answered.”

The hard work was only just beginning. Lincoln proposed a policy of “malice toward none, with charity to all.”

Positive illusion or depressive realism? We’ll never know. Soon Lincoln would belong to the ages. But the dream lives on, awaiting another Lincoln to realize it.

***
Previous posts:

The Normal Paradox
Normal: It Ain’t What It’s Cracked Up to Be
Reckoning with Evil 
Ghaemi's A First-Rate Madness: The Conversation Heats Up
Why We Need to be Asking the Questions

The Ghaemi Conversation: Why We Need to be Asking the Questions

This is my fifth installment in our conversation on Nassir Ghaemi’s “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness.” My previous post made note of the fact that two myopic scribblers posing as NY Times reviewers trashed Ghaemi for “practicing history without a license” and as being “unrealistic in his beliefs.”

The trash-talkers, needless to say, entirely missed Ghaemi’s point: Namely, that “normal” is highly over-rated and that (the right kind of) crazy can be an enormous asset when the chips are down. This is something I have simultaneously known all along and has never occurred to me. Then I opened Ghaemi’s book, and - pop! - the two contradictory halves of my brain reconciled.

I have devoted the better part of 12 years to urging my fellow bipolars and depressives to acknowledge the strange gifts that our conditions confer. In fact, crazy often leaves normal for dead. If you have trouble with this proposition, try imagining what the ceiling of the Sistine Chapel would have looked like with someone chronically normal up there on the scaffolding.

My guess is two coats of beige.

Mind you, normal looks pretty good when our illness has the upper hand. But over the long haul, trial by ordeal has a way of imbuing us with the kind of strengths that those the pathetically normal cannot even begin to comprehend.

Fine, I hear you say. A little bit crazy may be fine for artists and eccentric capitalists, but for high political office? With the world on the brink of economic collapse? Surely, the situation calls for someone with an even temperament in the Oval Office, right?

You tell me. No-drama Obama has been in the hot seat for nearly three years. Are you happy?

Meanwhile, the current crop of Republican Presidential candidates - declared and undeclared - are vying for who can come across as the most crazy. What is wrong with this picture?

Do you see in our future the end of the world brought to you by Fox News, with Sean Hannity and Bill O’Reilly congratulating themselves on saving us from the evils of big government?

Can our past at least tell us something about what is going on? Funny you should ask. Dr Ghaemi serves up Lincoln and Churchill - two well-documented depressives, the latter slightly bonkers - who admirably rose to the occasion in times of crisis. Likewise, JFK and FDR leaned more toward the abnormal than we tend to acknowledge.

But that is only half the story, according to Ghaemi. Hitler, it turns out, was far more normal than we give him credit for, at least until 1937 when his physician put him on a mind-altering meds cocktail (don’t get me started on meds compliance). Meanwhile, beneath the whacko exteriors of Nixon and George W Bush lurked temperaments bordering on the pathologically sane.

Six years ago, at the American Psychiatric Association’s annual meeting in Atlanta, I heard Nobel Laureate Eric Kandel explain how his exposure as a boy in Vienna to the brutalities of Nazism got him started in psychiatry. Psychoanalysis, which passed for psychiatry back then, offered "perhaps the only approach to understanding the mind, including the irrational nature of motivation and unconscious and conscious memory."

"How,” Dr Kandel asked in his Nobel autobiography, “could a highly educated and cultured society, a society that at one historical moment nourished the music of Haydn, Mozart, and Beethoven, in the next historical moment sink into barbarism?"

Could normal be part of the problem? suggests Ghaemi in his own way. Can so-called normal individuals and whole populations even, in times of uncertainty and hardship and crisis, subscribe to crazy beliefs, make irrational decisions, and sanction unspeakable acts?

This is the kind of discussion we need to be having as the Presidential campaign kicks into gear.

Next: The NY Times refuses to take up this discussion.

Previous posts:

The Normal Paradox
Normal: It Ain’t What It’s Cracked Up to Be
Reckoning with Evil 
Ghaemi's A First-Rate Madness: The Conversation Heats Up

Ghaemi's A First-Rate Madness: The Conversation Heats Up

This is my fourth installment in our conversation on Nassir Ghaemi’s “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness.” In times of crisis, Ghaemi tells us, we don’t send in someone chronically normal to do a crazy man’s job.

In essence, when the situation calls for seasoned lunatics such as Lincoln and Churchill, the worst thing that can happen to us is to entrust our fates to the likes of George W Bush and Richard Nixon.

The chronically normal may be okay for normal times, Ghaemi lets us know. But when the going gets tough, the normal wimp out. In these situations, their brains and life experience let them down. Creative solutions fail to present themselves, they become irrational, they crack under pressure, they make appallingly bad decisions.

By contrast, the crazy ones (at least those with the right kind of crazy) rise to the occasion. Not only do creative solutions come easily to them, they view events with far greater realism and are able to mobilize others to their cause. Plus - remarkably - they are the ones who display grace under fire. They are the ones as cool as a cucumber.

Wait a second! you say. George W and Nixon had to have been crazy. How else can you explain their inexcusably bad leadership?

Easy, says Ghaemi in so many words. They were normal.

And Hitler?

Okay, Hitler requires some explanation. The short version, according to Ghaemi, is that Hitler lost his marbles only after a quack physician put him on a mega-cocktail of barbiturates, amphetamines, and steroids.

This makes no sense, you say.

Right, absolutely. Moreover, we can say Ghaemi is being highly speculative and interpretative, and is exercising great selectivity in his case studies. Moreover, it’s easy to retrospectively go back over old facts and find any pattern you’re looking for to fit your hypothesis - a point I ironically learned from Ghaemi himself when he gave an APA talk a number of years back on the dangers of spinning clinical drug trials data.

Indeed, two NY Times book reviews take Ghaemi to task for precisely these and other points.

“Practicing history without a license,” is Thomas Mallon’s verdict in the Aug 19 NY Times Sunday Book Review.  “Unrealistic in his beliefs,” is how Janet Maslin concludes her Aug 10 NY TImes review.

Okay, Mallon is perfectly correct when he calls out Ghaemi for his superficial gloss of Harry Truman. Says Mallon:

Ghaemi even argues that the successes of “levelheaded” Harry Truman don’t refute this part of his thesis, since Truman wasn’t “handling major crises” during what Ghaemi seems to regard as an eight-year cakewalk from Hiroshima through Korea.

I admit to missing this completely. Otherwise, I would have cited Ghaemi with a speeding violation. Ghaemi glosses over Ike in a similar fashion. Ironically, Ike experienced depression earlier in his career and he doesn’t get anywhere near the credit he deserves for his skillful management of the Cold War.

Both the Ike and Truman examples occur in one obviously hastily written paragraph on page 223 of the book, and my guess is Ghaemi probably wishes he struck it out. Indeed, Maslin, sensing weakness, plants her dagger in precisely the same spot:

He even navigates entirely around figures who do not fit any of his theories. Ronald Reagan is branded [as normal], but “Reagan never faced a Cuban Missile Crisis.” Dr. Ghaemi drops his name, but can’t pigeonhole him at all.

It would be easy to dismiss Mallon and Maslin as myopic scribblers who know nothing about mental illness and totally missed the point, but then I would have to tar some of my readers - people who clearly know what they are talking about - with the same brush. Says Gina:

It seems to me that all sociopathic leaders (Stalin, Idi Amin, etc.) started out somewhat "normally" and often charismatic.

And what kind of metrics were they using to gauge "normal" back then? If you weren't yelling gibberish and frothing at the mouth, you were probably normal. If you could think rationally, do math problems, etc. you were probably normal.

In another post, Gina says:

John, after reading a few chapters of the book, I gotta say - I really agree with Thomas Mallon's review.

I hear you, Gina. Ghaemi is presenting a proposition that is not only difficult to swallow, but may in fact be completely wrong. Moreover, Ghaemi is on shaky ground when he spins the likes of FDR, JFK, and MLK as being on the right side of crazy.

Indeed, we could take every example of Ghaemi’s and argue an equally valid case the other way, namely that George W Bush was crazy, Lincoln was normal, and so on. That’s why I find history so fascinating. There are no absolutes. Wouldn’t it be great if we had a population intelligent enough to support history bars, modeled on sports bars, where people could walk in off the street and argue over a few beers why the hell George McClellan proved himself so indecisive and inept at Antietam when he knew Lee’s battle plan in advance?

Oops - Ghaemi asks precisely that very question in his book. The whole normal-crazy thing again.

I would argue that McClellan was a narcissist rather than normal. Ghaemi rejects the whole principle of narcissism, but it’s not a matter of who is right and who is wrong. There are no right or wrong answers, here. Only interpretations.

This is where I was coming from when I introduced Ghaemi’s book as a conversation. And starting the conversation is Ghaemi’s big issue - namely, that normal isn’t what it’s all cracked up to be. And that crazy can be good.

I have been writing about this for the best part of 12 years. It’s a very tough argument to make, particularly when your illness has the upper hand or if you are an innocent bystander who desperately wants your son or daughter or sibling or loved one back.

Last year, I keynoted the Kansas State DBSA conference in Manhattan. Someone asked me a question about famous people with mental illness.  

"I like to say to people," I replied, "we give you the gift of civilization and how do you treat us? You marginalize us."

I went on to say:

We discovered fire. I don't care if nobody wrote this down. Anyone crazy enough to go out into a burning forest and bring a flaming twig back inside a cave was not normal, was not thinking linearly, okay?

And just everything, from discovering America to painting the Sistine Chapel to writing Beethoven's Ninth to great poetry, great works of literature, to Isaac Newton, great works of science. I mean, literally, every field of human endeavor, we brought the world the gift of civilization and we get marginalized.

Indeed, if it weren’t for the crazy people, we’d still be shivering in caves. We need to acknowledge the gifts within us, to shout it out to the world: I’m crazy and proud.

Society has a way of viewing normal as all-good and mental illness as all-bad. When bad things happen, be it an individual in a shopping mall running amok or someone with too much power starting a war, we look for explanations in the DSM.

Dr Ghaemi lets us know this is highly stigmatizing. Absolutely. No question about it. Quibble all you want with Ghaemi, but let’s not lose sight of the big picture.

As I said, this is a conversation - let’s keep it going. Let’s keep arguing ...

Previous posts:

The Normal Paradox
Normal: It Ain’t What It’s Cracked Up to Be
Reckoning with Evil 

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. 

Normal: It Ain't What It's Cracked Up to Be

This is my second installment in our conversation on Nassir Ghaemi’s “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness.” (See The Normal Paradox.) Dr Ghaemi is by no means the first to comment on the positive association between manic-depressive tendencies and outstanding achievement, but he goes much farther by calling “normal” into question.

Basically, Dr Ghaemi is asking: If the right kind of crazy is optimal in times of crisis, what does that say for normal? Can’t we at least regard normal as serviceable in a pinch? No, is his unequivocal conclusion.

The basic fallacy about normal, if I am interpreting Dr Ghaemi correctly, is that this condition (yes, let’s call it a condition) leaves a lot to be desired, in the first place. Dr Ghaemi’s starting point is a study from about 50 years ago by one of Freud’s last disciples, Roy Grinker.

Dr Grinker screened a group of 343 college-age men, out of which he selected 65 he deemed to be in the middle of the mentally healthy range. Based on subsequent interviews, Grinker came up with a detailed list of mental health attributes for these “upright young men.”

There was, however, a major catch. These paragons of mental health suffered a severe case of “average-itis.” They had slightly above average IQs, their grades were average, and they were not leaders on the team sports they had played in high school.

In effect, their main positive attribute was they played well with others. Dr Grinker came up with the term “homoclite” to describe these drearily normal individuals - “those who follow a common rule.” Their goals were to fit in, do good, and be liked. Apparently they would grow up to become part of the “great silent majority” that Nixon infamously pandered to.

As Dr Ghaemi points out in his book, Dr Grinker’s homoclites represented the norm (a statistical average) and normal (an absence of illness), but hardly an ideal.

Which brings us to the $64,000 question ($523,412.54, adjusting for inflation): When the chips are down, would you truly want one of Grinker’s homoclites as your President or Prime Minister?

Or would you would feel more comfortable with someone who had been temporarily expelled from school, such as JFK?

Basically, Dr Ghaemi is validating what many of us have felt all our lives, namely: those of us who are not normal have no desire to become normal. True, we don’t want to be severely depressed or manic, either, or for that matter overly anxious or cognitively impaired or just plain feel miserable inside our own skins. We want to be better, to be ourselves.

But normal? No way, normal sucks.

I’ve related numerous times here on Knowledge is Necessity a knock-me-over-with-a-feather moment from a grand rounds I delivered three years ago to a psychiatric facility in Princeton, NJ, but it bears retelling and reinterpretation. Obviously, the individuals I was addressing were considerably smarter than your average homoclite. Nevertheless, we are living in a homoclite culture that apotheosizes normal. Just about everyone is in on the act. Just about everyone believes in the myth.

So here I was, trying to get through to a bunch of what I now know to be accomplished homoclites.

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

It was as if I had let rip a roof-rattler and everyone was too polite to laugh. Then I blurted out: “To me, you all have flat affect.”

Kelvin grade frozen stony cold silence.

Suffice to say, my talk was a disaster.

I naturally assumed that I had been wasting my time trying to get through to people heavily invested in the myth of normal. But, after reading Ghaemi’s book, maybe something else was going on, as well. Maybe these individuals suffered basic deficits in the empathy department.

There is a biological component to empathy, but a lot of it has to do with getting blindsided out of nowhere by whatever life has decided to throw at you. Picking up from Ghaemi’s account:

Franklin Roosevelt had a glorious future ahead as a homoclite golden boy. Mind you, FDR was no dullard. Quite the opposite. According to Ghaemi, FDR was an “omnivore and an innovator,” with certain manic tendencies consistent with a “hyperthymic” temperament. But, “until 1921, Franklin Roosevelt had led a charmed life.”

Everything changed at age 39, when he was felled with polio. He returned to public life three years later a different man. According to longtime friend and political associate, Frances Perkins, recounted by Ghaemi, “an untried flippant young man” underwent “a spiritual transformation,” emerging “with humility of spirit and with a deeper philosophy.”

Years later, Eleanor Roosevelt would remark: “He certainly would have been President, but a different President.”

So here I was, in Princeton, talking to a bunch of mental health professionals who couldn’t see the merit in even “a little bit” crazy, who could not even relate to the possibility that a good many of us do not want to be like them. That, to people like us, normal sucks.

Naturally, I could understand why they wouldn’t want to be like me. But could they not, at least, validate my creativity and other traits the way I value their stability? Could they not acknowledge that maybe they, too, could benefit from some of my strange gifts?

Introspection, enthusiasm ... empathy?

The "Normal" Paradox: Is Obama Mentally Unfit to be President?

Okay, before we start, let me make it clear: This is my thought. It belongs to me. I take full responsibility.

But the book I just finished reading, “A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness” by Nassir Ghaemi, has cleared the path for me to jump to this conclusion.

Dr Ghaemi is a professor of psychiatry at Tufts University. The book is hot off the press.

I will have much more to say on “A First-Rate Madness” and Dr Ghaemi in a bit. Let’s just say for now that this is the book of the year, that every word will give you something to think about (even the prepositions), that you need to buy it right now, that you need to read it cover to cover, and that you need to discuss it with everyone who knows how to breathe.

Okay, let’s get started:

Soon after election day 2008, I posted a blog piece on HealthCentral entitled, The Presidency: Temperament is the Real Issue. As you will recall, at the time of the election, the world was in economic free-fall. But the real concern was not the economy so much as which candidate possessed the best temperament to handle the crisis.

Virtually every babbling head at the time weighed in on the topic. Joe Klein, writing of Obama in Time magazine, observed: "His preternatural calm has proved reassuring ... "

By contrast, during the campaign, voters were unnerved at the spectacle of an impulsive and mistake-prone John McCain barely able to contain his rage. As I noted in my blog piece:

Obama was seen as "unflappable," in short, the type of person you would want first on the scene if you happened to be pinned under a car about to explode.

Okay, I take it all back.

A year after Obama took office, Jacob Weisberg, in a piece on Slate subtitled “How Obama's cool, detached temperament is hurting him and his party,” wrote:

His relationship with the world is primarily rational and analytical rather than intuitive or emotional. ... His tendency to focus on substance can make him seem remote and technocratic.

But Weisberg limited his analysis to Obama’s apparent failure to connect emotionally to the masses rather than his emotional incapacity to manage crisis. In short, when the center cannot hold, even Obama’s worst critics would agree that the last thing we want is a crazy person in the control room.

No! says Nassir Ghaemi most unambiguously. The last thing, in effect, we want is normal. According to Dr Ghaemi:

“No drama” Obama might be considered the epitome of mental health. We like our presidents moderate and middle-of-the-road - psychologically even more than politically. But psychological moderation is not what marks our great presidents. Can we applaud passion, embrace anxiety, accept irrationality, appreciate risk-taking, even prefer depression? When we have such presidents - the charismatic emotional ones, like Bill Clinton - we might have to accept some vices as the price of their psychological talents.

Dr Ghaemi is by no means the first in making a case for abnormal tendencies as leadership virtues. Joshua Shenk's 2005 "Lincoln’s Melancholy," for instance, brilliantly documents how Lincoln’s personal failures and his lifelong history of depression paradoxically molded him to take charge in the face of the greatest-ever challenge to the US.

As I noted in my mcmanweb review, Lincoln and His Depressions: “Lincoln’s melancholia allowed him to see events with preternatural second sight.” Dr Ghaemi refers to this as “depressive realism,” a gift shared by Churchill, Gandhi, Martin Luther King, and others.

But Dr Ghaemi tells us a little bit manic is also a good thing, exemplified by FDR and JFK. The base temperaments (hyperthymic) of these two Presidents may have been poles apart from the likes of Lincoln and the rest, but what all these great leaders shared in common were lives characterized by struggle and personal setback. Thus - born different, shaped different. And in crisis situations, different - not normal - is what we want.

Crazy, in effect, is normal to us. You know it, I know it.

Thus, of all things, when crunch time came - while the world around them was going bananas - the crazy ones - Lincoln, Churchill, JFK and the others - turned out to be the sane, level-headed ones.

They stayed calm, they listened, they identified with others. Moreover, they grasped what needed to be done, took charge, articulated their vision, rallied their troops. And they acted. If something went wrong, they owned the disaster, learned from their mistakes, made the necessary course corrections, and rose to the occasion - again and again and again.

Here’s where it really gets interesting. “Normal” individuals, says Dr Ghaemi, are singularly unsuited for crisis. Their brains were built for handling predictable situations in quieter times. When the unexpected occurs, they are typically at a loss. What seems to be happening, according to Dr Ghaemi, is their world view is totally out of sync with actual events. They don’t know what to do. They make fatal mistakes that they compound by rationalizing and justifying. Thus, in the case of Nixon with Watergate:

Faced with the greatest political crisis of his life, he handled it the way [a normal person] would handle it: he lied, and he dug in, and he fought.

In a similar fashion, George W Bush went weird on us. But here is the punch line: According to Dr Ghaemi, both Nixon and Bush were perfectly normal. Call Nixon delusional and paranoid. Call Bush stupid and irrational. But you’re wrong on all counts, according to Ghaemi. Until 1973, Nixon was the most successful person on earth. And all through his life, everyone wanted to be friends with George W.

But when faced with crisis, both Nixon and Bush essentially lost their bearings. Can you see the stigma issue here? Dr Ghaemi certainly can. We’re afraid to attribute success to crazy, but we are all too quick to assign it to failure.

But Nixon had to have been crazy. No, says Dr Ghaemi. What looks like crazy were normal individuals reacting to crisis in a normal way. A crazy person (or at least the right kind of crazy person), in effect, would have reacted in a way that came across as normal.

Confused? Throw away your conventional wisdom, says Dr Ghaemi. Normal isn’t always an asset. And there are clearly times when normal is neither the rational nor the best course.

So, perhaps now you can understand the title to this blog. Where we needed a Lincoln or a Churchill or a JFK, we elected someone with an even temperament. Crazy world we live in.

***

This is the opening to many more blog pieces based on Dr Ghaemi’s highly illuminating “A First Rate Madness.” I am looking forward to your comments and to a lively discussion. Stay tuned ...

Don't miss it

Dr Ghaemi will be featured tonight - Mon, Aug 8 - on The Colbert Report. 

Stigma-Buster of the Year: Nassir Ghaemi

When times are good and the ship of state only needs to sail straight, mentally healthy people function well as political leaders. But in times of crisis and tumult, those who are mentally abnormal, even ill, become the greatest leaders. We might call this the Inverse Law of Sanity.

Thus opens a feature piece in today’s Wall Street Journal, Depression in Command, by Nassir Ghaemi (pictured here), Professor of Psychiatry at Tufts. The piece is based on his new book, due out on Aug 4, "A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness."

Lincoln, Churchill, Gandhi, and King are the case studies cited in Dr Ghaemi’s article.

Similarly, an article in this week’s Newsweek, Madman In Chief, riffing off Ghaemi, concludes:

In Ghaemi’s view, even our supposedly crazy leaders were too sane for their times, and the nation suffered. When Richard Nixon faced the Watergate crisis, “he handled it the way an average [normal person] would handle it: he lied, and he dug in, and he fought.” Similarly, George W. Bush was “middle of the road in his personality traits,” which is why his response to the September 11 attacks was simplistic, unwavering, and, above all, “normal.”

So should we bring on the crazy in 2012? At the very least, we should rethink our definitions and stop assuming that normality is always good, and abnormality always bad. If Ghaemi is right, that is far too simplistic and stigmatizing, akin to excluding people by race or religion—only possibly worse because excellence can clearly spring from the unwell, and mediocrity from the healthy. The challenge is getting voters to think this way, too. It won’t do to have candidates shaking Prozac bottles from the podium, unless the public is ready to reward them for it. Amid multiple wars and lingering recession, maybe that time is now.

Dr Ghaemi is by no means the first to note the positive association between mental illness and extraordinary achievement, but no one has done it with such clarity and impact. Ironically, Dr Ghaemi informed me two months ago at a social function at the Ninth International Conference on Bipolar Disorder in Pittsburgh that he had a hell of a time finding a publisher.

I first ran into Dr Ghaemi in 2002 in Philadelphia at the American Psychiatric Association’s Annual Meeting. Back then, he belonged to a minority that questioned the efficacy of using antidepressants on patients with bipolar or with bipolar-like symptoms. Plus, he was writing on the obscure psychiatrist-philosopher Karl Jaspers and other cool stuff.

Listen to Dr Ghaemi for even a few minutes and you are going to learn a lot. I sought out Dr Ghaemi at future conferences and we developed a correspondence and friendship. It is no exaggeration to say that a lot of what you read on Knowledge is Necessity derives from seeds he planted in my mind over the years.

In 2006, Dr Ghaemi wrote an unbelievably commendatory blurb for my book, “Living Well with Depression and Bipolar Disorder.” He was being gracious, but hardly charitable. Trust me, had he thought my effort was the worst piece of crap shoved between two covers he would not have minced words.

I am looking forward to running a series of pieces based on “A First-Rate Madness” as soon as I get my hands on the book. Meanwhile, even prior to publication date, its presence is being felt. Already, people are starting to rethink mental illness in a positive way. A conversation is starting to take place. The title to this piece is no hyperbole. This could be big.

The DSM-5: Science vs Scientism

Just a quick note before I start packing for Kansas. Nassir Ghaemi MD of Tufts (pictured here), who has helped me enormously in understanding the fine points of my illness over the years, has cited one of my blogs pieces here with approval.

In a blog post on Medscape, Dr Ghaemi neatly encapsulates the DSM-5 debate. To quote at length:

In recent months, there has been back-and-forth between the heads of DSM-III (Robert Spitzer) and DSM-IV (Allen Frances), on one side, and the leaders of DSM-V (David Kupfer and colleagues), on the other. Frances in particular has been vocal in articles in the Psychiatric Times and the British Journal of Psychiatry; his critique sums up this way: 

Changes in DSM-V should not be made unless strong scientific evidence exists to do so. A conservative baseline mind-set appears to exist such that revisions should always err on the side of not making a change unless notably strong evidence exists for change. The rationale, as Frances describes it, is partly so that the psychiatric profession is protected from rapid and unnecessary changes in nosology.

Dr. Frances does not seem to question the validity of his assumptions: Should we have a very high threshold for making changes? Should we be erring on the side of not making changes? 

As John McManamy notes, this would ensure that we would forever be mired in the "Groundhog Day of 1980", the last time anyone in psychiatry had the courage to structurally change our nosology.
Science, yes; scientism, no.  We should not let claims of science blind us to data that are good enough, or to current practice that has the virtue of not requiring change but the vice of being unscientific.  

As I noted in other pieces here, the DSM-5 is not a science project. Instead of an academic publication that maybe 30 people would read, the DSM is a real world document relied upon by millions. Ironically, in the name of science, the DSM-5 is leaving in place ancient diagnostic criteria the defies both science and reality (such as not acknowledging the depression-bipolar spectrum).

As Dr Ghaemi concludes:

Over time, revolutionaries tend to become conservatives, and reaction engenders counter-reaction. There is a psychological law of inertia, as the writer Henry Adams observed: What exists is valued simply because it exists, and much more effort is needed to push the boulder of dogma into motion than to leave it alone. Perhaps the physicist Max Planck is sadly all too right that new scientific truths are routinely resisted by prior generations, who are rarely convinced, and rather are only accepted by a changing of generations.

Do Antidepressants Work?

In 2002, the July 2002 Prevention and Treatment published a study by Irving Kirsch PhD of the University of Connecticut. The study analyzed the FDA database of 47 placebo-controlled short-term clinical trials involving six antidepressants. These included "file drawer" studies, ie trials that failed but were usually never published.

The study found that the mean difference between the drug and placebo was a "clinically insignificant" two points on the HAM-D depression scale.

In other words, going solely on these data, there is no rational basis for choosing to take an antidepressant, much less for doctors to be prescribing them.

There are two main arguments to rebut this conclusion, both raised in an editorial in this month's American Journal of Psychiatry. In the editorial, Sanjay Matthew MD and Dennis Charney MD (both of the Mount Sinai School of Medicine) use findings from the NIMH-underwritten STAR*D real world clinical trials in support, namely:

"Mean" data is misleading in that it fails to parse out those populations who truly benefit from an antidepressant as opposed to those who don't. Clinical observation reveals that for certain patients an antidepressant is a Godsend. The catch is we don't know in advance which patients are more likely to respond.

STAR*D made an attempt at this, finding, amongst other things, that depressed people with anxiety or substance use, those with melancholic features, and those with a certain gene variation fare less well on antidepressants.

STAR*D also demonstrated the value of switching to a second antidepressant if the first one fails. The study showed that while at least half those in the study did not achieve a good result on their first try, according to the AJP editorial: "Patients who completed all phases of the study had an overall cumulative remission rate of 67%."

The editorial, however, failed to point out a major catch, namely that the 67 percent remission rate is theoretical, fully acknowledged by STAR*D. In the words of STAR*D's authors:

"The theoretical cumulative remission rate is 67% ... Note that this estimate assumes no dropouts, and it assumes that those who exited the study would have had the same remission rates as those who stayed in the protocol."

Ah, drop-outs. In the words of Holly Swartz MD of the University of Pittsburgh addressing a symposium at the 2006 American Psychiatric Association annual meeting: "If a patient doesn't stay on it, it doesn't do any good, even if it works."

The Kirsh study found a mean drop-out rate of 63 percent in it's review or clinical trials. This finding corresponds to other studies. In STAR*D, of 3,671 who entered the study only 123 made it to Round Four (keeping in mind that those who did well exited at earlier rounds).

Commenting on STAR*D, in a recent blog, Nassir Ghaemi MD of Tufts University noted that:

"Even if antidepressants worked in the short term (2 months, which is also what the meta-analysis assessed), one-half of patients who stayed on them relapsed into depression within one year. At the one year outcome, only about 25% of patients actually had remained well on and tolerated an antidepressant, much below the levels most clinicians seem to feel occurs in their clinical experience."

So what can we learn from all this?

First, beware of the exaggerated claims of the pharmaceutical industry and psychiatry. Also, beware of those making negative claims. All sides in this debate excel at spinning data.

Second - assuming you are not suffering from bipolar or a depression that behaves like bipolar - it is rational to choose to go on an antidepressant. Antidepressants may not work for everyone, but you may be one of the lucky ones.

Further, if your first antidepressant fails, it is worth persevering with a second or even a third antidepressant. Assuming you do not give up, your theoretical chance of success is two in three.

But also keep in mind you may find these meds intolerable and that relapse rates are high. They work in some cases, but they also disappoint. To conclude with Dr Ghaemi:

"We could all wish that clinicians' beliefs about antidepressants were true, or even half true. And perhaps they are the latter, for these agents surely have some uses in some settings; they are just not the dream drugs they seemed to be. ..."

From mcmanweb:

When Your Second Antidepressant Fails

The paradox: Perhaps if we don’t expect much of our antidepressant, we can get much better results.

Clinical Trials - What the Drug Companies Don't Report

So what is the most meaningful figure in an antidepressant trial? Apparently not the response rate, not the remission rate, not the Hamilton Depression scores. It's the drop-out rate, way too high whether going by industry figures or the FDA database. Clearly we are sending an unequivocally strong message that our medications leave much to be desired. Are any drug companies listening?

The Great Brain Robbery

In a recent blog post on Psychology Today, Nassir Ghaemi MD of Tufts University frankly discusses the "steroid problem of academia."

This concerns ghost authorship. What happens is common practice in journal publishing, especially in psychiatry. A drug company will design and write its own study, complete with its own spin favoring the drug in the study. Then the company invites respected academic researchers to front the study as authors. The study then appears in a medical or psychiatric journal. (For more detail how this works, check out my website article.)

What's in it for the "authors" is fame and academic distinction. In a university publish or perish environment, there is intense pressure on academics to rack up credits any way they can. The problem, says Dr Ghaemi, is that "some of our experts get their fame artificially, their achievements appearing greater than they really are."

In his blog, Dr Ghaemi reports how a department head actually encouraged him to engage in this type of fraud (he refused). Dr Ghaemi also reports how, fairly recently, a past president of the American Psychiatric Association and another luminary expressed complete surprise to him that this type of thing was going on. (This ignorance is astounding in light of the fact that eight or nine years ago, about a dozen journals worldwide ran simultaneous editorials highlighting the situation and promising corrective action in their own publications.)

Dr Ghaemi has devoted much of his professional life to researching the use of antidepressants in treating bipolar depression. His research has been influential in convincing psychiatrists to think twice before prescribing. His data shows that not only is the benefit problematic in a bipolar population, but there is risk of switching patients into mania and rapid cycling.

Not surprisingly, you will not find drug companies stampeding to fund studies to prove Dr Ghaemi right.

How serious is the problem? Early in 2008, in preparing for a grand rounds lecture I was to deliver to a psychiatric hospital in Princeton, I came across a 2006 study published in the American Journal of Psychiatry, which is put out by the American Psychiatric Association. The study concerned bipolar patients on Zyprexa, and was designed and written by Eli Lilly, which manufactures the drug.

The article listed Mauricio Tohen MD, DrPH as the lead author of the study. In all likelihood, Dr Tohen most likely did have a major hand designing and writing the study. A PubMed search of "Tohen M, olanzapine" reveals 92 published articles he authored between 1998 and 2008.

Dr Tohen is virtually unique in psychiatry in that he is affiliated with Harvard and Mass General Hospital AND is employed by Eli Lilly. In addition to Dr Tohen, the article listed eight other authors. Three of the names were instantly recognizable as prominent academic thought leaders.

According to the abstract of the study:

"Compared to placebo, olanzapine delays relapse into subsequent mood episodes in bipolar I disorder patients who responded to open-label acute treatment with olanzapine for a manic or mixed episode."

But the study data, not mentioned in the abstract, told a far different story. In fact, eighty percent of the patients in the study stopped taking their Zyprexa.

When I raised this to my audience of clinicians in my talk, I asked if anyone thought this was deceitful. All hands went up. I would go further, I said. I would say it's immoral.

Zyprexa is an antipsychotic with a high side effects profile, and it's not surprising that four in five bipolar patients choose not to take it, even if they are otherwise doing well on it. As Holly Swartz MD of the University of Pittsburgh told a symposium at the 2006 APA annual meeting: "If a patient doesn’t stay on it, it doesn’t do any good, even if it works.”

No doubt, I ranted and raved far too much in my talk, but as a patient I represent the greatest stakeholders in this debate. Am I going to end up in crisis - or worse - as a result of a well-meaning doctor sending me out the door with the wrong prescription based on deliberate misinformation?

Does anyone see a blatant violation of the "do no harm" principle at work?

I have no objection to productive partnerships between industry and academia. Indeed, drug companies would be incredibility stupid not to tap into this invaluable brain trust. Likewise, academics deserve to profit handsomely from any research that improves our chances of leading productive and rewarding lives.

What I object to is drug companies debasing psychiatry by employing its best and brightest as errand boys. Meanwhile, far too many highly-dedicated researchers are forced to leave the field due to lack of funding. We are left struggling in the dark. Our doctors get treated to infomercials.