Showing posts with label bipolar. Show all posts
Showing posts with label bipolar. Show all posts

Sunday, January 29, 2012

Rerun: Mahler: The Man Who Saw It Coming

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bernstein conducting the opening to Mahler's Fifth

Thursday, December 15, 2011

Illustrating Depression and Bipolar

As most of you who follow this blog know, at the beginning of this year I essentially blew up mcmanweb and started over. The site was in serious need of an updating, plus a facelift. My first phase involved a complete redesign, together with rewrites and reorganization of a lot of old articles. This consumed most of my time well into spring.

Throughout the rest of the year, I made incremental changes and additions.

I began mcmanweb around this time in 2000, with a small collection of articles on depression and bipolar. My goal was to create a comprehensive resource exploring mood disorders from every conceivable angle. Over time, I built up a collection of more than 300 artlcles (later pruned down to about 250), most written by myself, but with some personal accounts from contributors.

As the years went on, I essentially turned over just about all my content, save the pieces on famous people and personal stories. But by this time last year, it was clear to me that I had fallen way behind. I’ll just mention one of the matters I had to deal with, which involves design and the organization of my content.

The key to a successful website is making it easy for visitors to find what they are looking for, fast, and to facilitate their going deeper and wider. My basic navigation since the beginning has been successful -with content organized under categories such as Mood, Treatment, Science, Stories, and so on - and I stuck with what worked.

Thus, from my home page - as well as every page on the site - you can click on a category, which will take you to a landing page with the articles containing the information you are looking for.

But how do you bind a site together? At the same time, how do you differentiate between categories? How, in essence, do you lend coherence to the reader’s experience?

This time, I decided that a collection of old (and a couple of new) master’s paintings would define the look and feel to mcmanweb. A different old master would illustrate each category. Moreover, I carried forward these same old masters into every article. Thus, a Rembrandt for all my DSM articles, a Vermeer for my Treatment articles, and so on.

So here I am - today - nearly a year after I started the project when it occurred to me that I never explained my choice of illustrations to my readers. I just remedied that a few minutes ago, with short explanations on all my landing pages, which I have reproduced here. So without further ado ...

The pic to illustrate Mood is a close-up of La Tour’s “Magdalen at Night.” The woman seems to question her very existence. We have all been there.

The pic to illustrate Behavior is a close-up of Holbein’s “Henry VIII.” The monarch’s defying the Pope and killing off half his serial wives takes care of the seriously disturbed side of the personality equation. His sixteenth century rock star status - he was an accomplished lutenist, singer, organist, and composer, and a generous patron of the arts - captures the creative and positive side. Mind you, Henry’s way of resolving personal domestic quarrels can also be regarded as creative.

The pic to illustrate The DSM-5 is a close-up of Rembrandt’s “Moses.” Was there any other choice?

The pic to illustrate Treatment is a close-up of Vermeer’s “Cavalier with Young Woman.” I also use Vermeer to illustrate “Recovery.” The Treatment pic has two people in it, suggesting the wisdom of seeking expert help. The Recovery pic has a solitary woman actively engaged in a pursuit, reinforcing the notion that we are in charge.

The pic to illustrate Recovery is Vermeer’s “The Lacemaker.” Same explanation as above.

The pic to illustrate Science is a close-up of Dali’s “Exploding Raphaelist Head.” Dali was equally fascinated with Freud and the quantum building blocks of existence. This painting says it all.

The pic to illustrate Issues is a close-up of Raphael’s “The School of Athens.” Here we see Socrates engaging in a dialogue with a student. Socrates always challenged our cherished beliefs, strongly suggesting that anyone who claims to know the answers is a fraud. Indeed, if there is an absolute truth, there is no way of knowing it, much less knowing we know it.


The pic to illustrate Famous is a section from one of Warhol’s “Marilyn” prints. Marilyn’s iconic status made her a no-brainer to lead the parade of notables chronicled here. Warhol’s recasting of the same image in different shades suggests that what you see is not necessarily what you get.

The pic to illustrate Stories is Fragonard’s “A Young Girl Reading.” We all have stories in us. What the woman in the illustration does after reading one of them is up to her. Who knows, once she gets out of that chair.


The pic to illustrate Populations is a close-up of Bruegel’s “The Wedding Dance.” We may be one, but each one of us is also unique.

The pic to illustrate Relationships is a close-up of Klimt’s “The Kiss.” Ah, the possibilities. Alas, the ambiguities.

***

I cordially invite you to check out mcmanweb.

Wednesday, September 7, 2011

Relationships: My Bottom Line

Today I am going through the final run-throughs of a talk I will be giving tomorrow (Sept 8) to the International Bipolar Foundation, here in San Diego. The talk is on relationships. I’ve experienced the challenges of living with others from both sides of the equation, which means I will be frequently contradicting myself. That’s the way it is, in a complex universe with no easy answers ...

As Someone Living with Bipolar

I want to be able to laugh - laugh real loud - without my partner thinking I'm flipping into mania. I want to be able to get upset without my partner thinking I'm out of control. I want to be miserable without my partner giving me "the look." I want to express my visionary ideas without my partner thinking I'm grandiose. I want to make off-beat observations and dream without my partner playing her "practical" trump card. I want to bubble with enthusiasm without that "here he goes again" expression from my partner.

Furthermore:

I don't want to be told to snap out of it, take a chill pill, stop acting like a baby, be patronized, talked down to, and otherwise made to feel that I'm the weird and irresponsible one in this relationship.
 
I want my partner to say, "I understand," when I go to pieces for seemingly no reason. I want her to say, "I hear you," when I'm upset and distressed. I want her to laugh with me, cry with me. I want her to hear her say, "It's okay. I know where you're coming from. I would feel the same way in your situation."

In addition:
 
I want her to give me a swift kick in the pants when I need it. But I want her support and not her disapproval and judgment.
 
I need to feel safe. Emotionally safe. Otherwise, I'm the one walking on eggshells. Otherwise, I'm the one living in a constant state of stress.
 
That's a tall order for any would-be partner of mine.

Now, Speaking As a Loved One

Let’s own up to the hard cold truth: To live with a person with a mental illness is to live in an abusive relationship. Until we - patients - acknowledge this unpleasant fact of life, we will never make peace with ourselves and our loved ones. We will always be stuck in our recovery, perpetual victims, always finding fault in the people who love us, always blaming our outrageous behavior - illness-related or not - on our illness.

Here’s what I advised one person who complained her husband didn’t understand:

"When YOU act up or act out," I advised, "HE is the one who suffers." Even the most compassionate person in the world can only put up with this for so long.

They need to be hearing that we - the ones living with mental illness - are taking responsibility, even if we are having difficulty managing.

Something along the lines of: "I really appreciate this makes life hard on you. It's not easy for me to control my behavior at times, but I'm working on it, and I could really use your help on this."

Now, I said, instead of an adversary, you may have an ally. You've owned up to the problem. You've accepted responsibility. You've acknowledged your loved one's feelings. You've given him a reason to hope.

Believe me, this is music to a loved one's ears.

But talking a good game is not enough. If your loved one strongly hints at something, then you need to be acting on it. If this means putting the top back on the toothpaste, then put the top on the toothpaste.

Naturally none of this is easy when you are the one who is ill, but the stakes are enormous. Your loved one is the best thing going for you. Don’t turn him or her into a stranger.

As I concluded: "Your old approach hasn't worked. Time to try something new."

Okay, Here’s My Bottom Line

Safety, emotional safety. No matter which way we slice and dice it, no matter which side of the equation we’re on, it all comes down to emotional safety.

If I’m severely depressed, last thing I want to hear is someone telling me to look on the bright side of life, especially if you’re too damn stupid to take the trouble to see my reality. And if I feel like hopping on a plane right now to tell Obama off, last thing I want to hear is that we don’t have enough frequent flyer miles.

Looking at life as a loved one: Don’t put me in the situation where every time we go out I feel I have to dismantle a ticking bomb. And if I’ve reached the point where I’m telling you to snap out of it, it means I’m at the end of my tether. You are making my life miserable. I can’t take it any more. You need to be showing me that you’re willing to work with me. No stupid bipolar excuses. Don’t take my good will for granted. I don’t have an unlimited supply.

In either situation - living with it or living with someone living with it - you need to make me feel emotionally safe:

“I see your point.” “Good idea.” “I’m listening.”

And finally, the three magic words: “I know how you feel.”

***

All of you are invited to my talk. For further details, click the link below:

International Bipolar Foundation
Lecture: Relationships and Coping with the Day-to-Day Stuff

Thursday, Sept 8
5:30-6:00- SOCIAL
6:00-6:45-LECTURE
6:45-7:00- Q & A
Location:
Sanford Children's Research Center, Building 12
Address:
10905 Road to Cure, San Diego 92121
(Off of Torrrey Pines Road, La Jolla)

Wednesday, August 3, 2011

Relationships: How Does Bipolar Figure Into It?

I’ve spent the last few days working on a talk I will be giving here in San Diego to the International Bipolar Foundation on Thursday, Sept 8. My talk will be on relationships, which I am an expert in, having been in and out of two marriages. Let’s pick up on the action, two-thirds into my rough draft ...

Okay, let’s throw bipolar into the equation. Same stressful situation. Who is the one likely to freak out? The so-called normal one or the one with bipolar?

How many think the one with bipolar?

Okay, stress looms large in bipolar. We have genetically vulnerable brains. We are hardwired to over-react to what goes on around us. In times of stress, our limbic systems are over-activated. Our prefrontal cortex tends to go off-line.

Also, our brains have difficulty filtering out the world around us. We get overwhelmed very quickly.

Can anyone make a case for the so-called normal one freaking out?

Keep in mind, crazy people don’t have a monopoly on freaking out. Freaking out is a perfectly normal response to stress. So, can you imagine situations where the normal person is the one freaking out and the person with bipolar is as cool as a cucumber?

I can imagine a bunch of them. Keep in mind, crazy is normal to us. We’re used to disasters and to facing challenges. When our world comes crashing down on us, it’s often no big deal. Paradoxically, we are often in far better shape to deal with the situation.

This isn’t just some wacky idea of mine. Nassir Ghaemi in his new book, A First-Rate Madness, contends that a life-time without being tested leaves one ill-prepared to handle crisis. The great leaders have never had that problem. Think - Lincoln, Churchill, Gandhi, Martin Luther King.

Also, a lot of us think and perceive differently. We connect dots in very unusual ways and come up with amazingly creative ways of looking at situations. Often, this means solutions present themselves in an instant - as events unfold - so there is no crisis to begin with. No reason to freak out for us.

But this ability to think and perceive differently also works the other way for us. We can sniff out bad stuff well before it happens. Contrary to what many may believe, we don’t simply get excited over nothing.   

Rather than look at people as normal vs crazy, I look at people as linear vs non-linear.

This is the way most people think most of the time:


This is the way a lot of people like me think a lot of the time:



So what’s four like? Depends. Everything may be okay. Or it could be a good reason to freak out.

What’s 28 like? Same thing. Depends. Could be okay. Perhaps reason to freak out.

So, here we are. Same situation. Two completely different brains.


We are never going to see eye to eye. You’re reacting to 4. I’m reacting to 28. How do you think that’s going to work?

So - third rule of relationships.


If you perceived the same stuff the other person did, you might be freaking out even worse.

Unfortunately for us non-linear people, the linear people are in the majority. We have to conform to their world. Their world is totally stupid and makes no sense to me, but there you go - I have no choice but to try to fit in.

As I like to joke: We're peanut butter people trying to fit into a tofu world governed by Vulcans.

***
International Bipolar Foundation
Lecture: Relationships and Coping with the Day-to-Day Stuff

5:30-6:00- SOCIAL
6:00-6:45-LECTURE
6:45-7:00- Q & A
Location:
Sanford Children's Research Center, Building 12
Address:
10905 Road to Cure, San Diego 92121

Wednesday, June 29, 2011

Mahler: The Man Who Saw It Coming

This is from a mcmanweb article I wrote in 2004. My appreciation for Mahler has only deepened since then. Enjoy ...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bernstein conducting the opening to Mahler's Fifth

Sunday, June 5, 2011

Remembering Marilyn

Marilyn would have been 85 on June 1. I wrote this 10 or 11 years ago for mcmanweb. I would write a much different piece today, with far less emphasis on bipolar, and hopefully I will get around to writing that piece. In the meantime ...

On April 10, 1962, Marilyn Monroe arrived on the set of the bedroom farce, "Something’s Got To Give," for costume and screen tests. Producer Henry Weinstein described her as "at her best," but later that same evening he found her unconscious from an apparent sleeping pill overdose. Weinstein pleaded with the executives at Fox to delay shooting, but with the studio teetering on financial collapse as a result of the white elephant, "Cleopatra," they badly needed their most bankable star to bail them out.

Marilyn most likely was dealing with bipolar. And, of course, she was Marilyn. An AMC documentary from the early 2000s, "Marilyn Monroe - The Final Days," recounts what happened next:

Shooting was delayed a week while Marilyn went to New York to be with her mentors, Lee and Paula Strasberg. She returned energized, but with a bad cold that rendered her cinematically hors de combat. The studio rejected their own doctor's recommendation that production be postponed a month. One week later, Marilyn reported to work, only to collapse on the set the next day.

A short time earlier, US Attorney General Robert F Kennedy had entered Marilyn’s life. Marilyn confided in Weinstein of her impending first date and sought his advice on what kind of questions she should be asking. A week later, when Weinstein enquired how it was going, Marilyn cheerfully replied, "I don’t need any more questions."

Then there was Robert’s older brother, President John F Kennedy. Marilyn skipped a day of shooting to pant her famous rendition of "Happy Birthday, Mr President" in a gown that anticipated Jennifer Lopez by 40 years.

Meanwhile, the set at Fox resembled an armed camp, with director George Cukor at odds with both Marilyn and producer Weinstein, frustrated actors, an unhappy crew, and Fox executives on the warpath over Marilyn’s absences.

But the Marilyn captured on film completely belies the sound and fury behind the scenes. The screen fairly lights up with her presence, and a nude pool scene, painstakingly reconstructed from footage in the vault, stands as Exhibit A for why there has been no one like her before or since.

But soon after the pool scene, she disappeared for the weekend, then called in sick. When she returned to the set, she seemed to lack focus. Speculation has it that RFK may have broken off the affair.
By now, filming was 11 days behind schedule. Marilyn had worked for but 13 of 30 production days.

When she called in sick for the 17th time, Fox fired her. Marilyn was humiliated and began believing reports that she was all washed up, but then she rebounded to wage a spirited public relations campaign which resulted in the studio doing a complete about-face, signing her to a $1,000,000 two-picture contract. With shooting on "Something’s Got To Give" set to resume with a new director, Marilyn was back with a vengeance.

Then, days later, on the morning of August 5, Marilyn’s housekeeper noticed lights on in her room. She opened the door to discover why. Marilyn was dead from an overdose of sleeping pills. She was 36.

Marilyn’s bipolar is the most likely explanation for the incredible and unpredictable ups and downs that governed her final days and resulted in her tragic ending. Testimony from her personal physician and the fact that her mother was institutionalized lend credence to this view. Clearly another factor was the sheer magnitude of her personality (with elements of narcissism and borderline personality disorder entering into it).

A vulnerable person physically and mentally not ready for the demands of shooting another film, she had been placed in the impossible position of carrying an entire studio’s fortunes on her shoulders. Add to that her fears that maybe she could no longer live up to her larger than life Marilyn Monroe persona, and add to that the deflation of her grandiose bubble that she could be a future President’s wife. Who knows what else was going through her mind? Something had to give. Something did.

Thursday, May 19, 2011

When Anxiety Butts Heads With Mood

I just finished rewriting my old mcmanweb article on anxiety and mood, which I expanded into two articles: Anxiety in Depression and Bipolar, and The Mood and Anxiety Connection. Below are three snippets from the two articles, thoughtfully stitched together for your reading pleasure ...

Emil Kraepelin in his classic 1921 "Manic-Depressive Insanity" had this to say about what he called "excited depression":

It is here a case of patients who display, on the one hand, extraordinary poverty of thought but, on the other hand, great restlessness. ... Mood is anxious, despondent, lachrymose, irritable, occasionally mixed with a certain self-irony. ...

And here he is expounding on "depressive or anxious mania":

A morbid state arises, which is composed of flight of ideas, excitement, and anxiety. The patients are distractible, absent-minded, enter into whatever goes on round them, take themselves up with everything ...

Unbelievably, the DSM-IV is silent on both anxious depression and anxious mania. The DSM-5, due out in 2013, would change this somewhat, with the new diagnosis of "mixed/anxiety depression," but nearly a century after Kraepelin, the people who should know better can't bring themselves to acknowledge the obvious in mania.

Mixed Depression/Anxiety

Filed under "Depressive Disorders" is the proposed DSM-5 diagnosis of "mixed depression/anxiety." This involves "three or four of the symptoms of major depression" (a straight depression diagnosis requires at least five symptoms). One of the symptoms must include depressed mood or loss of pleasure. The depressive symptoms must be accompanied by "anxious distress."

The draft DSM-5 defines anxious distress as "having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen."

In essence, the DSM-5 is part-way to acknowledging that anxiety can be both an illness and a symptom of another illness. Depression, psychosis, sleep, and eating and other conditions already share this dual status. Indeed, in this particular area, the DSM-5 harkens back to the pre-modern DSM-I of 1952 and DSM-II of 1968, which viewed much of mental illness as the result of an underlying emotional disturbance called "neurosis." (More serious was "psychosis.")

According to the DSM-II, "anxiety is the chief characteristic of the neuroses." In a manner of speaking, anxiety both drove neurosis and could be one of its main symptoms, along with depression. Back in those days, symptoms were viewed as maladaptive responses to one's surroundings.

In other words, anxiety and depression and mania and even schizophrenia were seen as failures in our ability to cope. As naive as this may appear today, there is considerable merit in the old view that anxiety is inevitably to be found at the scene of the crime in almost any mental illness, whether as the principal or the accessory. Mix despair with anxiety and we're immobilized, unable to pick up the phone. Change it to a racing mind and we're yelling into that same phone, freaked out over some slight disturbance.

In one sense, the world is way too close and immediate, on the other too far and disconnected. One day we're treading water surrounded by thrashing ravenous crocodiles. The next we're Major Toms, a million miles from nowhere, cut off from humanity.

Mixed Mania/Anxiety

The DSM-IV does not recognize this state, and neither would the DSM-5. From a clinical level, mixed mania/anxiety would probably be impossible to diagnose, so why bother? But on a personal level, we need to acknowledge reality. It's easy, really. Simply imagine a state of irrational worry combined with failure to control one's impulses. Thus, you may find yourself fretting about your situation at work. Fairly normal. What's not normal is storming into the boss' office and quitting your job, with no other job lined up. This happened to me. It wrecked my life, but I'm grateful I ONLY quit my job. In the frame of mind I was in, I could have done something much worse.

An additional twist: Walk into any support group, and you will hear participants discussing their "mood triggers." Excessive worry, for instance, may cause you to lose sleep, which makes you a sitting duck for mania. Or it may set off depression, which later sets up mania. Keep in mind, depression and mania never operate in isolation. We are talking about a constant two-step, in this case with an additional dance partner.

My Driver’s Test Mood-Anxiety Hell

From a blog I did on HealthCentral ...

My anxiety levels are through the roof. I have just met a wonderful woman who lives [40 miles away] in San Diego. I NEED to pass this test. The inspector asks me to turn on my left signal. I turn on my right signal. It's all downhill from there. FAIL! I feel lower than a snake's belly. I'm a loser, an idiot. The woman I just met is going to dump me for sure. We work it out. She will help me. I book another appointment for August.

Two weeks later, I call her in a panic. I have just discovered DMV videos on YouTube. More than a hundred of them. Ten top reasons drivers fail the test. Something about forgetting that Burma is now called Myanmar. Automatic fail.



I’m never going to pass this test!



Yesterday. I’ve willed my heart down to merely 300 beats a minute. Turn left, the inspector instructs.

What did he mean by that? I wonder.

He's scribbling in his clipboard. One turn and already I've given him something to write about! I'm doomed! The test ends. The inspector tells me I have a tendency to overthink and panic. Duh! He tells me I've passed. I passed! I refrain from hugging the inspector.

Friday, May 13, 2011

Was LBJ Bipolar? The Case For ...

Blogspot lost my second post on LBJ, from Wed. Here it is ...

Yesterday, I made an unassailable case for the fact that LBJ, the 36th President of the US, did not have bipolar. Okay, let’s assail it.

Bipolar is as much defined, if not more so, by its context as its symptoms. Call it the Zen koan disease: If a crazy person is leading a fully productive and enviable life, does he have a mental illness?

Of course not.

Yes, LBJ had a lot of characteristics you could describe as bipolar, but at age 58, in 1966, he was indubitably the most successful man in the world. He assumed the Presidency in 1963 following the assassination of JFK, then was elected in his own right in 1964 by what was then the widest margin in history. Two years later, with a string of Great Society initiatives, he was on the cusp of being regarded as the greatest President ever.

His entire public life prior to that was three unbroken decades of stellar achievement. His talent and drive would have made him most-likely-to-succeed in any situation, but LBJ was also the beneficiary of extraordinary good luck. At certain critical points in his career, key opportunities would open up - a Congressional or Senate seat becoming vacant, a leadership position in the Senate ...

His lucky streak continued into his Presidency. Change was in the air, and the public willingly placed its faith in their new President, who was uniquely qualified to get things done. Johnson knew he had a rare window opportunity that would close fast, and he acted without hesitation.

The Great Society was a calculated risk. A major tax cut - which pleased the business community no end - stoked the economy, which in turn filled government coffers. As long as prosperity increased, no one was about to question how the wealth was distributed.

But raised hopes also ignited pent-up frustrations. A six-day race riot in Watts LA in the summer of ’65 signaled that racial divisions ran far deeper than people ever imagined. As African-Americans became more assertive, white backlash deepened. The “Solid South,” which had faithfully voted Democratic, was shifting to the Republican side.

Meanwhile, baby boomers, who had grown up in far different circumstances than their parents, were now beginning to assert themselves. By any standard, LBJ was by far the most progressive President in history, but an increasingly vocal population on the other side of “the generation gap” viewed him as a relic.

Nevertheless, the situation was manageable. A booming economy and a successful Great Society overseen by an attentive President would see America through its crisis of identity.

That’s when LBJ’s luck ran out.

In 1965, LBJ decided to increase troop levels in Vietnam from 75,000 (mostly in a limited role) to more than 200,000 (as full-scale combatants). His strategy was based on the misplaced notion that the North Vietnamese leader, Ho Chi Minh, in the face of overwhelming US military might, would come to his senses and seek a peaceful settlement. He didn’t.

By 1966, Johnson’s position was untenable. The one thing that hawks and doves could both agree upon was there was no end in sight to this war. Doris Kearns Goodwin’s 1976 “Lyndon Johnson and the American Dream” at this stage portrays an increasingly irrational President for the first time in his life at a total loss.

Johnson’s War had a zillion fall-out effects. Among them, it overheated the economy and kick-started inflation, which would hobble economic growth for decades to come. It also drained vital financial resources from the Great Society, as well as diverting crucial executive oversight, virtually killing the infant in its crib. This set the scene for disenchantment over “big government” programs and the right-wing counter-revolution to follow.

Finally, resentment over Vietnam brought all of society’s underlying divisions to the surface. The nation may not have been in anarchy, but to a casual observer of the TV news in 1967 and 1968 it certainly seemed that way.

As the situation grew increasingly worse, LBJ retreated into his shell, taking advice from only a small cadre of trusted and sycophantic advisers. Instead of making the necessary  course corrections, he only justified his disastrous decision-making. At this stage, in the last year of his Presidency, Goodwin gives us the impression of a country being run by a mad man. She uses the terms “obsessional” and “delusional” to describe his thinking:

In the past, Johnson had displayed a fine sense of discrimination about his political opponents, recognizing his enemies today might be his allies tomorrow. Now he became unrestrained and reckless, creating a fantasy world of heroes and villains. Members of the White House staff who had listened to the violent name-calling were frightened by what seemed to them signs of paranoia.

She continues:

Suddenly, in the middle of a conversation, the President’s voice would become intense and low-keyed. He would laugh inappropriately and his thoughts would assume a random, almost incoherent quality as he began to spin a web of accusations.

On March 31, 1968 - virtually unable to govern and with his popular support eroding by the day - Johnson announced that “I will not seek, nor will I accept, the nomination of my party for another term as your President.”

LBJ left office at the beginning of 1969, never to return to public life. He died Jan, 22 1973, an embittered and broken man, two days following Nixon’s inauguration to a second term, one day after the announcement of a Vietnam cease-fire and the announcement of a Nixon plan to dismantle the Great Society.

So there you have it, the bipolar Zen koan revisited. A man who lost his mind, his job, public affection, and his legacy. Would it be fair to describe this man as living with bipolar? You tell me ...

Wednesday, May 11, 2011

Was LBJ Bipolar? The Case Against ...

Did Lyndon Baines Johnson live with bipolar disorder? His accomplishments clearly illustrate he was no ordinary man while his failures point to a tragic figure out of touch and out of control. The diagnosis has been loosely bandied about in relation to the 36th President of the US. But is it accurate?

Doris Kearns Goodwin in her 1976 “Lyndon Johnson and the American Dream” offers some excellent insights. Goodwin had a ringside seat into LBJ’s descent into his dark side when she joined his staff in 1968 in the waning months of his Administration. LBJ took a fatherly interest in his young intern, and she became his confidante and student, a relationship that continued into his retirement in 1969 to his death in 1973.

The B-word is not mentioned in Dr Goodwin’s account (it would have been the MD-word back then), nor does she even suggest that LBJ had any diagnosable condition. But she does make ample reference to his legendary mood swings, unquenchable drive, over-bearing nature, and times of despair.

Bipolar, along with any mental illness, is a hindsight diagnosis, only applied after things have gone horribly wrong, never in anticipation thereof. Walk into any DBSA support group and you will hear accounts of busted lives, careers derailed, relationships gone sour, intense psychic pain. While Abe Lincoln could have easily pulled up a chair and made himself at home (as one with depression, not bipolar), LBJ would have been out the door in nothing flat.

Bipolar? We are talking about a man with an unbroken career arc that began as a congressional aide in 1931 and culminated in his ascent to the Presidency in 1963. In between, he served in the House, the Senate (where he reshaped the institution as Majority Leader), and Vice-President. Along the way, there was nary a hiccup to his career, no crisis of faith, no time in the wilderness, no gap in his resume. On top of that, his marriage to Lady Bird held rock steady.

Sound like the kind of person you would run into at a support group? I didn’t think so. Yet, as Goodwin is quick to point out, behind the mask of success was a man with many insecurities, sometimes barely able to hold it together. At one point, in a deep funk, he instructed an aide to alert the press that he was dropping out of his race for the Senate. The aide, in consultation with Lady Bird, ignored the request.

Johnson was in his element when he was in control, whether as a college student seizing the moment or as a young politician on the make or as a wheeling-dealing Senator who was arguably the most powerful man in Washington outside of Ike. Then he made the seemingly disastrous career move of serving as JFK’s Vice President. Even though he was given numerous important responsibilities, it was Kennedy’s show, not his.

Dr Goodwin gives us the impression of a man dutifully showing up for work, loyal to his boss, but not engaged, almost in a stupor. Had JFK served out his full term in office, with the strong probability of another, LBJ may well have had his time in the wilderness, but an assassin’s bullet changed everything.

What follows is the stuff of legend. A reanimated LBJ, with a singular sense of purpose, led a bereaved nation through crisis and on a mission to complete what his martyred predecessor had started. Then he initiated the most ambitious effort ever to reshape the face of the nation with his Great Society programs. Civil rights, voting rights, housing rights, Medicare - the scope of his achievements was unprecedented. Education, the war on poverty, model cities, clean air, clean water - there was no end in sight.

Alas! All of us who lived through the sixties know the tragic ending to this story. Many attribute Johnson’s decision to expand US military involvement in Vietnam to an act of madness, but, as Goodwin points out, Johnson’s key advisers from the Kennedy Administration were thinking the same way.

The policy may have been mad, but it was a rational act conducted by rational men, very much in character with how America did business. But Goodwin points to some complicating elements. The key one was that it was impossible to run both the Great Society and an overseas war at the same time. Johnson went ahead with both anyway.

Something had to give. Major understatement.

More to come ...

Monday, April 4, 2011

Where Does Hypomania End and Mania Begin?

As part of my overhaul to mcmanweb, I've scrapped most of my old articles on the diagnostic aspects of bipolar and replaced them with new pieces. The following is extracted from a much longer piece on hypomania. Enjoy ...

The DSM mandates that if psychosis is present, then it has to be mania, not hypomania. Otherwise the only separator is severity, and here the DSM is highly confusing and contradictory. On one hand the DSM reassures us:

The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization ...

On the other, symptom number seven (a direct copy and paste from the mania symptom list) tells us:

Excessive involvement in pleasurable activities that have a high potential for painful consequences ...

So - wait! First, we're being informed that there is nothing to worry about. Next, we're being told to go to DEFCON One. Which one is it?

There are no easy answers, but one possible solution is to eliminate symptom seven in hypomania and make it mandatory (rather than merely optional) for mania. In other words, if the individual is entering the danger zone - putting his or her livelihood, relationships, and safety at risk - then it is mania, not hypomania.

Another piece of the puzzle is control. In my article on mania, I suggest my own diagnostic guide:

Behavior must be out of control to the point that subject can no longer responsibly manage his or her affairs or reasonably interact with others. ... Thinking must be out of control to the point where subject has a grossly distorted perception of him or herself and his or her surroundings, and is no longer capable of making realistic or responsible decisions.

Whereas with hypomania, it's more like this:

Subject may exhibit unusual or unexpected behavior, but is still capable of responsibly managing his or her affairs and interacting with others. ... Subject may have a mildly distorted perception of him or herself and his or her surroundings, but is still capable of making realistic and responsible decisions.

Finally, there is the matter of presentation. In euphoric states, I would contrast a "magnanimous larger than life presence" (mania) with a rather more diminutive "sociable charismatic presence" (hypomania). In dysphoric states, I would contrast a "hostile menacing presence" with an "unpleasant mildly threatening presence."

But nothing is ever that simple. In bipolar, our brains are always in perpetual motion, so even in a seemingly benign hypomania there is always room for worry.

***

New mcmanweb bipolar articles:

Bipolar Disorder - Really a Cycling Illness
Bipolar I and Mania
Bipolar II and Hypomania

Wednesday, March 30, 2011

Forget Bipolar - We're Really Talking About Cycling Illness

I'm head down-ass up replacing my old bipolar diagnosis articles on mcmanweb with new ones. Following is an extract from one of my drafts ...

When I step out of the house, I go through the same mental checklist as everyone else - keys, wallet, phone, on and on. But I'm also performing a systems check on my brain. This sort of thing runs in the background all the time, but when I'm headed out the door the exercise assumes a quality of anal high drama, like a shuttle launch countdown ...

Make sure my head is screwed on right.


Ha! If people only knew. I live with bipolar. Most of the time I go about my life as if I don't have it, but that is only because I take nothing - including an operational brain - for granted. Breathe! I remind myself. All systems go. I'm ready to face the day.

It's Really All About Cycling

Bipolar is entirely the wrong term for my illness, your illness. "Cycling" is far more apt, suggesting the brain in perpetual motion - moods, thoughts, perceptions, everything - nothing standing still, everything shifting, nothing predictable.

But is there there anything up ahead I can at least anticipate?

Day slips into night, the moon waxes and wanes - my brain is a veritable I Ching. I may head out into the world cool, calm, and collected, but will my brain be working for me two hours from now when it really matters? I already know what I'll be like on the way home, a wrung-out dish rag, too spent to stop off at Trader Joe's. Is there enough food in the fridge?

Breathe! I remind myself. Breathe.

Way back in 1854, the French psychiatrist Jean-Pierre Falret came up with "la folie circulaire" (circular insanity) to explain the extreme mood changes he observed in his patients. The pioneering German diagnostician Emil Kraepelin coined the term "manic-depressive insanity" to describe what he saw as a much wider and more complex phenomenon. Nevertheless, cycling was a central piece to the puzzle. In the 1921 English translation to his classic "Manic-Depressive Insanity," Kraepelin describes the illness as including "the whole domain of so-called periodic and circular insanity."

What we call bipolar is an enormously complex illness, but strip it to its most essential element and what we're left with can be best described as a "cycling illness." Simply knowing that we have ups and downs is not sufficient. What we need to know is how these ups and downs relate, what is driving them, and what else is interacting with the dynamic.

Our "episodes" (depressed, manic, hypomanic, and mixed) only make sense in the context of the cycle that propels them. Is our hypomania (mania lite), for instance, a prelude to a crushing depression, or is it a warning that we are about to get swept up in a full tidal mania?

And what about the type of things that play havoc with our cycles, such as staying up all night to complete an assignment or cross-country travel?

In the second edition to "Manic-Depressive Illness" (2007), Goodwin and Jamison make it clear we are talking about more than one cycle, from the glacial pace of the shifting seasons to daily circadian rhythms. Kraepelin emphasized that there was a lot more to cycling than just mood, including intellect and volition, and not necessarily in sync. This would account for seemingly exotic but in fact fairly common variations to our moods such as "excited depressions" and "inhibited manias."

Let's rephrase: We are talking many cycles, not just one. Cycles within cycles, if you like. Throw any one of them out of whack and there goes your precision timing, your sense of being in control. Then life becomes a mad scramble, like juggling spinning plates. Inevitably, it happens - the plates crash to the floor. But always in a perverse slow motion that gives you just enough time to make the horrible realization - yet once again - that things have slipped away from you. And there you are, alone in the awful bitter aftermath, left to pick up the pieces.

Thursday, March 24, 2011

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 ...

Thursday, March 17, 2011

Rerun: A Kraepelin Appreciation (Why his 1921 opus is way ahead of the psychiatry of 2011)

I've been running a series of pieces on Hagop Akiskal. This is the dude Akiskal looks up to. From June last year ...

I've just been reading Emil Kraepelin's classic "Manic-Depressive Insanity." Never heard of him? Bet you heard of Freud, who was born the same year. All Kraepelin did was "discover" manic-depression, schizophrenia, co-discover Alzheimers, and found diagnostic psychiatry. His body of work, based on meticulous observations of thousands of patients in German asylums, spans from 1893 to 1927. "Manic-Depressive Insanity" was published in English in 1921, extracted from his much larger "Compendium."

Kraepelin's pioneering approach to classifying mental disorders inspired the modern DSM-III and IV, though - ironically - he has to be rolling in his grave over how both editions got manic-depression all wrong. Let's hear from the source what manic-depression really is:

Manic-depressive insanity ... includes on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases of amentia.


Plus "colorings of mood" that embrace both pathology and personality.

All these diverse elements, claims Kraepelin, "represent manifestations of a single morbid process."

In other words, someone who cycles up and down, gets depressed, flips into mania, has messed up thinking, and has stuff going on with moods is suffering from one illness, not  five, not twenty-five. Equally important, the depression itself (even without evidence of mania) is strong evidence of manic-depression, not something else. All this was revolutionary thinking way back in the first part of the previous century, and still remains ahead of the curve in the first half of this one.

Kraepelin's view of manic-depression, then, is vastly more inclusive than the modern DSM's "bipolar disorder," which does not recognize recurrent unipolar depression. Modern psychiatry, instead, lumps recurrent depression with chronic depression, which explains why antidepressants don't work for a good many individuals and can even cause harm.

You would think the DSM-5 would fix this, but do psychiatrists listen?

In addition to offering finally-detailed clinical descriptions of depression and mania, Kraepelin identified transient "mixed" states. Here, we can truly appreciate the master at work.

Kraepelin asks us to conceptualize not just mood cycling up and down, but also intellect and volition, but not necessarily in sync. Thus, instead of pure mania (flight of ideas, exalted mood, pressure of activity) or classic depression (inhibition of thought, mournful moodiness, irresoluteness) we variously have:
  • Depressive or anxious mania (where depression takes the place of a cheerful mood).
  • Excited depression (where flight of ideas is replaced by inhibited thought).
  • Mania with poverty of thought (instead of flight of ideas).
  • Manic stupor (a depression with cheerful mood).
  • Depression with flight of ideas (instead of inhibited thought).
  • Inhibited mania (flight of ideas with cheerful mood and psychomotor inhibition).
If you find, say, "manic stupor" confusing, don't worry, Kraepelin has your back. Sample:

The patients are usually quite inaccessible, do not trouble themselves about their surroundings, give no answer, at most speak in a low voice straight in front, smile without recognizable cause, lie perfectly quiet in bed or tidy about at their clothes and bed-clothes, decorate themselves in an extraordinary way, and all this without any sign of outward restlessness or emotional excitement. ...

The reason you probably haven't heard about all this is because the DSM flies in the face of reality by categorizing a mixed state as full-blown depression coexisting with full-blown mania. The DSM-5 would partially redress this, but comes nowhere near to restoring Kraepelin.

Kraepelin has been referred to as the father of modern psychiatry, but that does him a grave injustice. If Kraepelin were alive today, he would take a match to the DSM and start over - I've heard that sentiment expressed by a good many reform-minded psychiatrists. His "Manic-Depressive Insanity" from 1921 remains state-of-the-art. The psychiatry of 2011 has a lot of catching up to do.

Tuesday, March 8, 2011

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 ...

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More Akiskal on mcmanweb:

The Mood Spectrum
Multipolar Depression
The Fear and Anger Equation

Monday, March 7, 2011

Please Tell Me It's Bipolar

 Following is an article I recently posted on mcmanweb ...

"Do all bipolar people lie or is it just my husband?"
"My boyfriend is bipolar and is coping with heroin."
"Is this an episode loving another man not my husband?"
"My husband is bipolar and every time we talk he always tells me I'm attacking him."

This is a sampling of queries that frequently arise on HealthCentral's BipolarConnect, where I contribute as an "expert patient." Are you beginning to spot a pattern?

First, let me say that these people and others are asking in good faith. They are going through hell. They are at the end of their rope. They are desperate for answers.

But I am also reading into their questions the type of answer they wish to hear, namely:

Yes, bipolar is the cause of [your husband's lying, your boyfriend's drug habit, your own infidelity, your husband's inability to discuss issues with you, and on and on]. Bipolar is a highly treatable illness, and with the right treatment these problems will all go away.

If only ...

These days, bipolar is copping a bad rap for no end of inappropriate behaviors. I think a lot of it has to do with the raised awareness of bipolar. Now, when people encounter behavior they don't like, the prime suspect is bipolar. Ironically, raising awareness may have raised stigma.

Inevitably, when responding to these questions, I point out that a mood disorder is very different from a personality issue or a personality disorder. Yes, there may be a connection. Yes, a mood episode obviously influences behavior. But first, it pays to make a separation.

To start, a mood disorder is morally neutral. Fluctuations in mood have nothing to do with one's personal character or values. Hitler may have had bipolar, but he was going to invade Poland, anyway.

On the other hand, there are complications. Hitler imprudently invaded Russia with winter coming on. Were it not for his unbalanced mental state, it is possible to imagine a far different outcome to World War II.

Psychiatry makes a very clear distinction between mood disorders and personality disorders. To vastly oversimplify, a mood episode is seen as "uncharacteristic" of an individual's baseline behavior. With a personality disorder, outrageous behavior is seen as embedded into an individual's make-up. With the former, the perception is that meds will quickly resolve the issue. With the latter, we see a far more problematic future.

Thus, you can see the logic in the desperate pleas of my readers. Please tell me it's bipolar, they seem to be saying. Then with a quick fix my abusive husband will become loving, my selfish wife will become considerate, my egotistical boyfriend will become understanding, my indifferent girlfriend will become caring.

Unfortunately, my correspondents almost always describe behavior far more indicative of a personality disorder than a mood disorder.

The bottom line is a loved one should not have to distinguish a bipolar episode from a personality disorder or just plain inappropriate behavior in the first place. Hurt is hurt, no matter what illness or condition or character defect you assign to it, and no one - for any reason - should have to put up with this type of abuse. But the people I hear from are willing to give their partners a second chance, to work with them, to help them. To give the relationship a chance.

If only, if only ...

Alas, I have to tell them probably not.

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More relationship articles on mcmanweb: Family and Relationship Fallout; Validating Family Pain; My Loved One Doesn't Understand - Really?; Emotional Safety - My Relationship Bottom Line; What Goes Up