Breaking Down Personality

The story so far: We all want happiness and love and meaning in our lives. The people who have this tend to have positive emotions, an integrated personality, life satisfaction, and virtues (such as courage and wisdom). But to get there, we need to have a strong sense of self-awareness, we need to "know thyself."

Personality is adaptive and non-linear, and evolved from three basic systems: 1) Habit (non-rational, tied to basic emotions such as fear), 2) Propositions (rational, tied to secondary emotions such as empathy) 3) Narratives (rational and also self-aware, allows us to change).

The above is from a lecture last week at the American Psychiatric Association's annual meeting by leading personality expert Robert Cloninger MD, detailed in two blog posts (here and here).

Okay, let's break down personality. The slide you see below dates from Dr Cloninger's work in 1993. It breaks personality into two separate but interconnecting branches, temperament and character.













Temperament is about our habit systems (which roughly equates to the ancient Greek concept of the "four humors") namely:

1. Harm avoidance - The fear system that mediates responding to punishment and pain.
2. Novelty seeking - Looking for pleasure, which leads to rage when frustrated.
3. Reward dependence - Allows us to be sensitive to social cues that in turn allows social intimacy.
4. Persistence - Allows us to deal with expectations about whether we will get rewarded or not. We see it in very conscientious people.

But these traits don't stand alone. They're always interacting with the person's character, namely their view of who they are and how they relate to the rest of the world. You can describe these in terms of three cognitive sets: 1) Self-directedness, 2) cooperation, and 3) self-transcendence.

It's the communication between all these that allows us to say whether someone is healthy and in a state of well-being. This in turn influences your overall sense of who you are, which in turn allows you to shape the rest of your personality.

Thus, we have a model of mental self-government that allows us to regulate the competing urges from our basic biological drives.

Fine, but if our mental self-governance is closer to anarchy, can we impose order? If it's closer to autocracy, can we loosen the reins? In short, can we change?

Let's back up. Below is Dr Cloninger's "temperament cube," that he developed in 1987.















Don't worry. We will compassionately spare you the details. The gist of the model is the interplay between three of the four temperaments: novelty seeking (high and low), harm avoidance (high and low), and reward dependence (high and low).

Thus, someone with low harm avoidance tends to be carefree and risk-taking while those with high harm avoidance are characterized as anxious and pessimistic. Combine high harm avoidance with low novelty seeking and worlds collide.

Note, on the corners of the top we see the four Cluster B Axis II personality disorders, together with their prime descriptors, thus: histrionic (passionate), antisocial (adventurous), narcissistic (sensitive), and borderline (explosive).

The bottom corners produce another set of (opposite) extremes. Thus, the antithesis to someone with explosive borderline traits would be a methodical and obsessional individual. Fortunately, most of us don't cluster into the corners.

But life isn't that simple. This is where mental self-government and its three branches come in:

1. Self-directedness equates to the executive branch that implements the rules and allows you to be responsible, purposeful, and resourceful.
2. Cooperation equates to the legislative branch that gives you the rules to allow you to get along with other people, so you can be flexible, helpful, and compassionate.
3. Self-transcendence (judiciary) gives you the flexibility to figure out when the rules apply and don't apply.

Voila, the "character cube."














The ones who seek help, Dr Cloninger said, tend to be schizotypal or depressed. Thus, if we look to the bottom corner of the cube, in Dr Cloninger's words: "I had a patient of mine describe this as, 'Life is hard, people are mean, and then you die.'"

This contrasts with those who hit the character trifecta with the Jungian prize of enlightenment and all the goodies that go with it. Those with the Freudian prize of being organized can take comfort in the fact that they can at least love and work.

Thus we see a spectrum from transcendence to psychopathology, with a lot of room in the middle, meaning there is no true separation between normal and abnormal personality.

In the slide below, the upper case letters (S,C,T) stand for high self-directedness, cooperation, and transcendence, while the lower case letters (s,c,t) stand for their polar opposites. Red is happiness, blue is sadness.














Take a look. If you're low in all three, you're really going to be depressed. And seeing that personality is fairly stable, you are likely to stay depressed. Not good.

But here's the good news: We can change, and change can occur fairly rapidly. Stay tuned ...

Who the Hell Are We and What Does That Have To Do With Our Recovery?

Picking up from where we left off:

It turns out the most consistent way of recognizing that someone is in a state of well-being is how well they've been able to express self-directedness, cooperation, and self-transcendence in their lives.

This translates into meaningful work, mutually caring relationships, and a sense of what's really important beyond out individual needs.

So says personality and well-being expert Robert Cloninger MD of Washington University (St Louis). Dr Cloninger was addressing a packed house at the American Psychiatric Association's annual meeting last week in San Francisco. I was in the audience as a journalist.

Medications are useful in getting us to stable, Dr Cloninger advised, and in putting us in a position to get started. Then the real journey begins. It all starts with knowing ourselves, having a sense of growth and self-awareness.

So who the hell are we?

Well, before we answer that question, we might first ask ourselves to define personality. Dr Cloninger's simple explanation: "It's the way we learn and adapt." Let's amplify that: "It's the self plus the internal and external forces that pull on the self."

Key features of personality, Dr Cloninger said, include:

• It's dynamic, and non-linear. "Get over the idea that it's fixed and written in stone."
• It is psychobiological, which includes the body, the analytical mind, and the intuitive and creative mind.
• It is organized. There is a basic design in all human beings that allow us understand and to communicate with each other.
• It is personal. Adaptive processes occur within the individual. We tend to get sidetracked comparing the differences between people, which is wrong. If we want to motivate someone, we need to figure out what is going on within them, what counts to them.
• It is idiographic. We are each unique.

Here's a key fact we tend to overlook: We have evolved over millions of years, and with it three major systems of learning and memory.

1. Habits and skills learning: Reptiles have this nailed. This is based on the quantitative strength of our synaptic connections. It is prelogical, not rational, and subjectively linked to basic emotions such as fear and anger and ambition. These habit systems demand instant gratification and tend to get in conflict with each other.
2. Semantic learning of facts and propositions: Mammals rule in this department. It is contingently logical and rational in a hierarchical sense, and is associated with secondary emotions such as empathy. Propositions bring order to the chaos of the demands of our basic emotions, but is not self-aware.
3. Intuitions and narratives: A uniquely human trait, the recognition that we are writing our own story. At once, we talking about pre-verbal and intuitive, rational and self-aware, modular rather than hierarchical. Here's the pay-off: "It gives us flexibility about the future. We can change. We can have hope. We can be creative and do things we've never done in the past and surprise everybody."

Ah, now we're getting somewhere. We've just gotten past the Table of Contents. Now we can begin to check out our Owner's Manual in earnest. Think of the slide below as a sneak preview.













Trust me, "Know Thyself" is where recovery starts, and Dr Cloninger is the leading authority. Much more to come ...

What the Hell is Well-being, Anyway, and Why Is It So GD Important?

Good title for a talk? Psychiatry tends to veer toward wonky titles, such as: "Developing a Positive Psychiatry of the Person."

Okay, let's go with that. Last week in San Francisco, at the American Psychiatric Association's annual meeting, I heard Robert Cloninger MD of Washington University (St Louis) deliver the type of lecture that justifies his reputation as a pioneer in that strange field that we simultaneously know everything and nothing about: personality and well-being.

"Well-being is the universal wish of human beings," Dr Cloninger opened. "We all want happiness, love, and a meaning of life that is greater than our individual self."

Obviously, this is something that you can't get in a pill, and therein lies the problem with our treatments. Response to acute (initial phase) treatment, whether with meds or talking therapy, is only moderate, and drop-outs, relapses, and recurrences are high.

But if clinicians are smart, Dr Cloninger went on to say, they will attend to what people want in life and build therapeutic alliances around that. On the other hand: "Getting people to do things they don't want to do doesn't work well."

There are four converging ways to measure well-being, Dr Cloninger told his audience:

1. Emotions: Namely positive ones, ie being happy.
2. Personality: It turns out that positive emotions relates to maturity in character. People who have a well-integrated personality also turn out to be happy.
3. Life satisfaction: People who are content with their lives don't have a lot of complaints.
4. Virtues: People who have them (courage, justice, moderation, honor, wisdom, patience, love, hope, and faith) also tend to be happy, mature, and satisfied with life. Reframing a goal to work on developing courage, for instance, may produce a better outcome than figuring out what to do with an anxiety disorder.

Well-being has little to do with income. Rather, there is an association with heritable personality traits, plus with meaningful work, mutually caring friendships, and spiritual values. Dr Cloninger cited Ed Diener's pioneering work that showed while personal income in the US has dramatically increased from the 1930s to the present, life satisfaction has remained static.

Over this time period, we have seen the introduction of all our psych meds and all our manualized therapies. We know these things are helpful, Dr Cloninger said, but "why isn't it making a dent" in these statistics?

So what's the key to well-being? It all starts with self-awareness, Dr Cloninger advised.

Check out the name of this blog. Much more on Dr Cloninger to come ...

What Does the Tango Have To Do With Recovery?

As you know from reading this blog, last week I was in San Francisco attending the American Psychiatric Association's annual meeting as a journalist. What I didn't report was my biggest knock-me-over-with-a-feather moment. Allow me:

On Thursday morning, I listened to Dean Ornish MD of UCSF. Dr Ornish is a celebrity doctor and author known for promoting smart lifestyle choices as the key to good health. His recommendations are all grounded in rigorous research, much of it his own. For instance, in a 1998 study published in JAMA, Dr Ornish found that patients can not only stop the progression of heart disease through lifestyle management, but can actually reverse it.

In fact, smart lifestyle reliably works across a range of illnesses (including depression), and can often replace invasive and costly treatment (or at least make the treatment work better). The catch is you have to do it, and therein lies the problem. "What's sustainable," Dr Ornish said, "is not fear of dying but joy of living."

Hold that thought.

Dr Ornish is no stranger to depression, having experienced a severe episode that sidelined him from college. Loneliness and isolation, he said, increases mortality 3.7 times. Depressed individuals are more likely to over-eat, smoke, drink, and work too hard.

You would think that making a few simple changes would be easy, right?

"'Dean, you don't get it,'" his patients told him. "'These behaviors get us through the day.'"

Getting through the day anyway they could was more important to them than living to age 86. In essence, these people could see no benefit to giving up smoking if it meant losing their cigarette-smoking friends, especially if there was nothing to replace those friends.

Meanwhile, the research on the benefits of positive lifestyle kept mounting up. In one 2008 study published in PLoS (JA Dusek lead author), researchers found that the relaxation response in trained meditators switched off cancer-promoting genes.

Changing our lifestyle actually changes our genes, Dr Ornish pointed out. But who wants to change their lifestyle? What Dr Ornish finally figured out was that will power was a nonstarter for individuals, as was the motivation to live longer. "Who wants to live long if you're depressed?" he asked.

What works, he said, is joy, pleasure, freedom. Up went a slide of two tango-dancers - Dr Ornish and his wife. Doing the tango was part of Dr Ornish's exercise routine.

That's when the lightbulb went off: Yes, we need to lead disciplined lives, but we are doomed to failure unless we incorporate fun into our routines. On my website are numerous articles about the virtues of good diet, exercise, yoga, meditation, and so on. We know all this stuff works, but what good is any of it if we give up?

Then it occurred to me: None of my lifestyle routines are based on iron will. They all have enjoyment incorporated into them. For instance, my "exercise" is daily walks, water volleyball, and (off and on) dancing. My "diet" is based on my love of cooking, where anything I throw together is both tastier and healthier than restaurant food. My "stress-management" is all about building contemplative time-outs into my schedule. Even my "meditation" has a fun twist - I play (rather badly) the didgeridoo.

Then I flashed back to some of my recent blogs - a whole series on play, a bunch of home-made nature videos. Guess what? When it comes to fun, I am very compliant. My "fun" routines may not be as beneficial as "serious" routines, but they work much better by virtue of the fact that I stick to them.

In the words of Dr Ornish: "Doing the tango makes your brain grow ... Some of the things that are most fun are good for you."

Dang! Why didn't I think of that?

This Memorial Day ...

This Memorial Day:

Our men and women are returning from two wars. They have witnessed things and felt things that those of us who stayed home have no clue. Their brains have been overwhelmed, their psychic beings shaken to the core.

This Memorial Day:

Our soldiers may leave the battlefield, but they cannot leave their memories there. Very high percentages are returning home with PTSD, depression, and other mental illnesses. Even those without full-blown symptoms have issues to deal with. Others are ticking time bombs. Suicide will claim more of them than enemy gunfire. Many will attempt to cope by turning to alcohol and drugs.

This Memorial Day:

Many brave men and women have no clue what is about to happen to them. They served as heroes, but, like many who served in Vietnam, may wind up homeless. They may be remembered for their bravery, but we will cross the street to avoid them.

This Memorial Day:

It's not just about flags on graves. It's about serving the people who served our country.

This Memorial Day:

Resolve to do something tangible. Advocate. Donate. Get involved with one of the veteran's organizations. Get involved with a mental health group making an outreach to veterans. Do something. Then keep doing it.

This Memorial Day:

It's our turn now.

New Imaging Studies Reveal Brains of Assholes

In a study about to be published in "Nature," researchers at the NIMH reveal the first-ever fMRI scans of assholes at work.

Said lead researcher Y Mee MD, PhD, "We've always known an asshole when we see one, but it never occurred to us to actually scan their brains. I mean, seriously, who would want to?"

Nevertheless, the researchers overcame their strong revulsion and recruited 10 assholes plus 10 control subjects.

"I mean - crap - I was ready to quit my job in the first five minutes of the study," said co-author I Hadinoff PhD. First the assholes filled out their intake forms completely wrong, then abused the staff when they had to fill them out again. Next, they kept pushing and shoving to be the first one into the MRI machine. But once in, they couldn't stop complaining.

This posed a special difficulty because study protocol required that first the assholes' brains be scanned while in a resting state.

"So here we are," said Dr Hadinoff, "having to be nice to these fucking assholes. No sooner do I get one calmed down than another one gets started, and next thing they're all setting each other off like mousetraps going off in a room."

One asshole lady complained that her no-good son-in-law refused to finish cleaning the leaves out of her gutter, as he had promised. A world-class therapist had to be called in to remind the individual that her son-in-law had fallen off the ladder while she was shaking it and had cracked nine vertebrae and would be a quadriplegic the rest of his life.

"But I'm on a fixed income," the woman retorted. "How the hell am I going to find affordable help?"

Said Dr Hadinoff: "You know that show where that guy does all those shit jobs? I'm on the short list for the Nobel Prize, but, believe me, I was ready to throw it all in and go to work standing up to my ears in cow shit. Seriously, anything had to be better than dealing with this shit."

Eventually, the researchers got the assholes settled down and were able to get images of their brains at rest. On close inspection, the scans revealed certain structural abnormalities to the posterior corpus rumpus section of the brain. (See image above.)

"It's uncanny," said Dr Y Mee. "It's as if their brains had 'asshole' written all over them."

Then the assholes were made to perform certain tasks while their brains were being scanned. In one task, the subjects were asked to imagine lying on a beach on a tropical island.

"What? I'm just supposed to lie there in the hot sun with all the mosquitoes and sandflies and who knows what?" was the typical response. "Screw you, I did that for my second honeymoon, and let me tell you, it wound up to be our first divorce."

In other tasks, the assholes were asked to imagine something good about a member of their family, any accomplishment they could be proud of, a waitress they were nice to, and something that went wrong that they were willing to accept responsibility for. They failed every task spectacularly.

As their brains were thus engaged, a certain part of the posterior corpus rumpus, known as the temporal anal cortex, lit up like a Christmas tree. (See image below.)


















"It's amazing," said Dr Y Mee. "For the first time ever, we are looking into the mind of an asshole - and the last time, I can assure you. Believe me, after what we went through, no one in their right mind is going to want to try to replicate our findings."

The findings are expected to provide valuable insights into radio talk show hosts, Fox News commentators, and antipsychiatry bloggers.

Drs Y Mee and I Hadinoff are at present in intensive therapy. Their prognosis is poor to miserable.

Judi Chamberlin is Dying, But She is Still Fighting Our Fight

Judi Chamberlin belongs to a generation of antipsychiatrists who got in the face of psychiatry and changed it. Equally, she helped shake patients out of their fatalistic mindset to one of feeling empowered. Judi, 64, is dying of COPD. Her insurer, UnitedHealthcare, has pulled the plug on her home hospice care.

Ironically, her insurer would be paying out far more money for back and forth visits to the hospital.

Judi has dedicated her life to fighting for the dignity of others. Now, she is fighting for her own dignity - the right to die in accord with her simple wishes. But her fight is never her own fight. It's always our fight as well.

Full story in the Boston Globe

Tooting from San Francisco - V: Mental Health Break

I’m at the Cliff House perched over the Pacific Ocean, drinking coffee and watching where the seals are supposed to be on the rocks. I lived in San Fran for about a year back in the mid-70s, and this is where I enjoyed coming to for my mental health breaks.

This is mental health break time. The American Psychiatric Association’s annual meeting is in its last hours and I’ve called it a wrap. I heard some excellent presentations this morning, which I will get to at another time. I’ll be flying out in a few hours. Time to close this laptop and enjoy the view ...

Tooting from San Francisco - IV: Dang- This is Interesting!

This is my fourth day in San Francisco at the American Psychiatric Association’s annual meeting. To recap:

Morning: Time off.

1:00 PM: I’m back on the job, checking out the posters. “Deep Brain Stimulation [DBS] of the Ventral Capsule/Ventral Striatum for Treatment-Resistant Depression” reads the heading to a poster.

“That does it,” I tell the researcher in an accusatory tone. “Now you’ve really gone out and confused me.” Helen Mayberg and others have already been applying the same technique to Brodman area 25 in the anterior cingulate, and yesterday I was treated to an equivalent of a masters class on the topic.

Now I have to learn about another area of the brain? I hold my ground. I demand my masters class.

1:45: I’m early for a session on “me-too” medications. Frederick Goodwin is on the panel, and we greet each other warmly. This is the first time I’ve seen Dr Goodwin since the NY Times published an account that irresponsibly smeared him in relation to a show that aired on “The Infinite Mind,” which used to be run on NPR.

The NY TImes piece was a mugging, and clinicians who should know better such as physician blogger Dan Carlat and psychologist John Grohol of PsychCentral engaged in the equivalent of kicking Dr Goodwin in the face. Antipsychiatry bloggers such as Philip Dawdy of Furious Seasons predictably piled on without checking the facts.

To the best of my knowledge, I am the only blogger who defended Dr Goodwin. I wasn’t sticking my neck out. The facts were - and still are - on his side. I was very pleased to see Dr Goodwin in a chipper mood. We enjoyed a very pleasant conversation, then I took my seat in the audience.

The first speaker, William Carpenter of the University of Maryland, made the telling point that new meds development is held up by the prevailing single disease mindset (Dr Carpenter used “paradigm,” but I forgive him). For example, we tend to equate psychosis with schizophrenia. Psychosis, however, features in other illnesses and conditions. Individuals with schizophrenia, in the meantime, have a lot more to contend with than just psychosis.

For instance, avolition (lack of motivation) looms large in schizophrenia. Yet, there is no med for this, and there may never be one if drug companies have to run clinical trials based on old precepts. Suppose, for instance, a drug company tested an “avolition med” on a population of individuals with schizophrenia. But if only say one-third of those being tested had to contend with avolition, then, said Dr Carpenter, the trial would fail.

Ironically, such a cognition med may be efficacious across a whole range of disorders. Dr Carpenter informed his audience that the FDA is aware of the situation and is working to fast-track cognition meds (Google “MATRICS”).

Dr Goodwin pointed out that clinical trials do not reflect clinical practice. For instance, those with severe mania can’t get into trials as it is impossible to obtain from them “informed consent.”

Clinical trials are based on finding results that apply across large populations. This, combined with “hierarchies of evidence” (which devalue smaller studies and clinical experience) are forcing patients “into a one-size-fits-all straightjacket.”

Here’s where the danger lies, according to Dr Goodwin: Treatment guidelines based on unrealistic clinical trials (but which are at the top of the evidence hierarchy) create uniform menus. These menus are increasingly being employed by government and private insurance to ration services.

For instance, what if third-party payers decided not to approve of the use of an antidepressant added to a mood stabilizer for bipolar patients because a large STEP-BD study did not find them effective across a large population?

Dr Goodwin described his experiences dealing with out-of-touch academic researchers back in the nineties. “I couldn’t imagine them ever managing a patient,” he said. (And they didn’t.)

Evidence-based medicine, Dr Goodwin said, is based on what we already know. Innovation tends to come from clinicians breaking the rules, which is how lithium and antipsychotics found their way into psychiatric practice. It isn’t just about the NIH translating scientific research into treatment.

4:00 PM: Afternoon posters. The first one I bump into is about unidentified “threadlike and/or spherical particles” in the cerebrospinal fluid of bipolar patients.

Dang! This looks interesting. Now I really have to budget my time. A few posters down: “Inhaled Loxapine Rapidly Improves Acute Agitation in Patients with Bipolar Disorder.”

Recall what Dr Carpenter had to say about the need to test for a specific part of the illness (such as avolition), not just the illness. Loxapine is an ancient antipsychotic, so we’re not talking about a new med, but the principle is the same. The treatment, if approved, would be taken on an as-needed basis, say when you felt yourself freaking out over a missed plane at midnight in Las Vegas airport (which happened to me). Unlike “popping a Klonnie,” sucking into the inhaler would work instantly, presumably without sedating effects.

Right now, we’re simply talking promising. Maybe the promise of the med won’t play out, but - dang! This looks interesting. There is only 30 minutes to go to this poster session and I’m still not out of the first aisle ...

This is John McManamy, live from my fleabag hotel room, on my way out to grab a burger.

Tooting from San Francisco - III: A Major Sea Change

I’m actually thinking with a clear brain. So THAT’S what it’s like. Trouble is I need to be winding down for sleep. To recap my day:

Tuesday 6:00 AM. I’m up way too early and can’t get back to sleep. I’m headed into my third day of the American Psychiatric Association’s annual meeting in San Francisco with precious little sleep in my bank account.

8:45 AM. I’m seated for my first talk of the day. “Have you heard the news?” I ask the psychiatrist next to me. I hand him a print-out. The heading reads:

“Breaking News: Psychiatry Comes Up with New Diagnosis of Asshole.”

The piece is a hard copy of a blog piece I wrote a couple of weeks back. We’re about to hear a talk by Robert Cloninger on “Developing a Positive Psychiatry of the Person,” and it’s nice to know I’m doing my bit.

“Treating symptoms is not enough,” Dr Cloninger opens. It’s all about well-being. Dr Cloninger has been a major paradigm-shifter in mapping out the fine points of personality and their interacting dynamics. Personality, he explains, is non-linear, involving the way we learn and adapt, plus the internal and external forces that pull on the self.

We are shaped by our genes and environment, but our self-awareness (a uniquely human trait) allows us to modify these influences and move forward with our lives.

Personal change, he said, can happen very rapidly, if you can get the person to recognize their strengths and weaknesses.

11:00 AM: I’m struggling to stay awake. Marc Schuckit of UCSD is about to talk on the fine points of the genetic and environmental influences involving alcoholism, and my cortex is running on empty.

I’m at the talk by virtue of Kenneth Kendler’s presentation the day before. Dr Kendler used alcoholism as an example of gene-environment interaction, and I figure this is a way of getting deeper into the topic.

I’m not disappointed. Dr Shuckit’s research into the area began some 30 years ago when he started asking a few simple questions. There are many causes of alcoholism, involving many genes and environmental influences, but Dr Shuckit noticed that when those with alcoholism described their early drinking experiences, they tended to remark about how they could drink everyone under the table.

The technical term is “level of response” (LR). These individuals need to have a lot more drinks to feel the same effect as their peers, and kids drink for effect. Once you get into the pattern of heavy drinking, Dr Shuckit said, then the environment kicks in: You hang out with heavy drinkers; they expect you to engage in heavy drinking.

Dr Shuckit has tracked more than 400 offspring of alcoholics and control subjects for 25 years, and found that LR is a reliable predictor of alcoholism. He is also getting a reading on the genes involved.

So, say you know that your 12-year-old has a genetic predisposition to LR, is there anything you can do about his environment to protect him? Different peers? Different expectations?

12:30 PM: I meet up with a good online buddy, Gina Pera, who has a great ADHD blog. Nearby, we grab some gyros and take them outside. Gina’s been a great moral and intellectual support to me, and I could literally sit out in the sun all day with her, but an afternoon of dark rooms beckons ...

2:05 PM: I walk in late to a very large packed room where an expert panel is discussing borderline personality disorder. What is wrong with this picture?

A mere three years before, at a featured lecture at the APA in Toronto, one of the pre-eminent leaders in the field, Joel Paris, spoke to mostly empty chairs. Earlier, at a bipolar session, one leading expert had been dissing the borderline diagnosis.

In three years, something has dramatically shifted in psychiatry. Earlier - at a session at the same time as Robert Cloninger’s - leading borderline expert John Gunderson had spoken to a packed house. Add to that the packed house from Dr Cloninger’s presentation.

At a brief pause in the proceedings, I ask the psychiatrist next to me what is going on, and he confirms my impressions. In essence, the bloom has gone off biological psychiatry, which translates into sending patients out the door with just a prescription. We’re seeing the pendulum swing back toward an earlier era when psychiatrists used to spend time working with their patients to find solutions to their personal problems.

It is reasonable to infer from this that the profession is becoming receptive to the goal of recovery.

It’s as if at some point in time in the last three years psychiatrists had suddenly woken up. I have no idea how this will play out in the real world, where psychiatric practice is dictated by the insurance industry and where old habits die hard. But I can assure you, this is a major story, perhaps the biggest event in my 10 years of reporting on mental illness, and one readily quantifiable - just count the people in the room.

4:00 PM: I am literally sleep-walking through the afternoon poster session. This is usually a great learning opportunity for me, my chance for one-on-one face time with the experts. But my brain isn’t tracking. I’m not engaged. No sense hanging around ...

5:00 PM: I’m back in my room at my fleabag hotel. Sleep, glorious sleep. One minute later it’s 8:00 PM. I get up and splash water on my face, taking an inventory of my brain.

My sleep is not messed up, I decide. I’ll be out like a light before midnight. Moreover, I’m taking tomorrow morning off. Late sleep. A little sight-seeing. Time to wind down ...