Mental Health Break No. 26,493,178 - A Walk in My Neighborhood

My daily routine is to calmly crank out my work from home till just before I'm ready to scream. That is my cue to head out for a walk. I'm 3,500 feet up in the mountains 40 miles east of San Diego. Today, I drove one mile as the crow flies to the entrance of a state park, which I had all to myself. I shot the pics from my iPhone. Enjoy ...

Mental Health Break No. 66,395,275 - A Walk in the Park

The walls are closing in. I need to get out of the house. Out of the neighborhood. I wasn't going to get anything done anyway. An hour later I'm in San Diego's Balboa Park having a great day - and here's the slide show to prove it.

Zen Moments

On the spur of the moment, I drove 40 miles to Balboa Park in downtown San Diego, where I stumbled into a Japanese flower arranging show. The style is called Ikebana, in which the actual bloom may play a supporting role to stems and stalks and branches and leaves. Suddenly, I was in another world. I shot these on my iPhone.  Enjoy ...

 

 

Thinking With Our Meat - Part II

Nature/nurture, mind/brain, genes/environment - today’s brain science is providing new insights into how we think and behave. To continue from Part I ...

At the 2003 APA in San Francisco, I heard Daniel Weinberger of the NIMH tell his audience about a study that came out of his lab, published in Science the year before (Ahmad Hariri, lead author). In the study, the researchers rounded up healthy subjects and put them into a brain scan machine (not all at the same time, I presume. I think they lined them up one at a time). The individuals were divided into two groups, those who had a certain variation to a particular gene, what they call the short allele to the serotonin transporter gene, and those who had the long allele.

The serotonin transporter - or serotonin reuptake pump - is the target of SSRI antidepressants. Based on this knowledge, researchers knew there had to be a genetic smoking gun somewhere, but they were stumped. The problem was they were looking for a "depression gene" or a "bipolar gene." Genes, unfortunately, don't code for the way we classify psychiatric disorders.

In 1998, for instance, a German team came to the conclusion that "no association between alleles conveying functional differences in serotonin transport gene expression and major depressive disorder or bipolar disorder could be found."

Basically, genes act as "on-off" switches. But they don't necessarily switch on "depression" or "bipolar" or anything else. Instead, they activate proteins that regulate how cells function and and organize themselves into interacting with other cells. This in turn may influence whether a certain individual is predisposed to depression or bipolar, but you're not going to find that out by looking for a direct link.

It's simple mechanics really. First link the gene to the cellular function it influences. Dr Weinberger and his team already knew that a certain region of the genome, SLC6A4 with the chromosomal address of 17q21, is responsible for the cellular activity that involves vacuuming excess serotonin from the synapse between the neurons.

But then what? What was the connection to behavior? On one hand, Dr Weinberger and his colleagues needed to build on the work of Arvid Carlsson's generation; on the other, they needed to throw away all their preconceptions.

As the study subjects' brains were being scanned, they were made to perform a simple cognitive task involving looking at images of "scary" faces. If you have any doubts about what a two-dimensional image can do to the brain, simply turn on Fox News without the sound. Seriously, just the sight of those idiots - don't get me started.

It turned out that the "short allele" people - that is, those with a certain variation to the gene in question - in reaction to the scary faces, a certain portion of their brains lit up like a Christmas tree. You guessed it, we're talking about the amygdala, which features mightily in my adventures with raccoons and skunks.

As we know, the amygdala mediates fear and arousal, and is directly and indirectly wired into all areas of the brain. Think of the amygdala as a simple smoke alarm. It can detect smoke, but it's too dumb to know whether the smoke is related to grilled meat or a five-alarm fire. The thinking areas of the brain will eventually provide you with the info you need to make a rational decision, but all that takes too way long to boot up.

In the meantime, it's prudent to sound the alarm, even if it is a false alarm. But what if the alarm is over-sensitive or won't shut off? It's one thing for your fight or flight response to kick in at the sight of a predator (or Dick Cheney with a face lift) at the door, but what if you keep having the same reaction to, say, the UPS guy?

When the amygdala goes off, we are reacting rather than thinking. We are operating out of fear. As Dr Weinberger explained to his audience, "this could be the first study to link genes to emotions."

What does this mean?  Let's turn to a closely related study:

About 35 years ago, researchers from the University of Otago recruited a "birth cohort" of more than 1,000 infants born in Dunedin, New Zealand, and subsequently assessed them every two or so years. Had my daughter (who was born in Dunedin) arrived five years earlier, she might have been part of that cohort. Then again, had she been born five years earlier, I wouldn't have been the father.

"Longitudinal" studies of this sort represent the gold standard of population research, as opposed to "retrospective" findings based on recalled events. Over the years, this cohort has been to medical and psychiatric and behavioral research what wild Tanzanian chimps have been to Jane Goodall.

On July 18, 2003, the journal Science published the latest installment coming out of Dunedin. The year before, the same research team had identified certain childhood risk factors in antisocial behavior, together with a strong link to a suspect gene (acting on the enzyme MAO-A). This time, the researchers (Avshalom Caspi, lead author) analyzed the cohort for stressful events over the past five years, such as death in the family, losing a job, or breakup with a partner and this time their attention was directed at the very same gene that featured in Dr Weinberger's study.

Lo and behold, of those meeting the criteria for at least four recent stressful events, 43 percent of the short allele people experienced depression vs just 17 percent with the long allele.

In a field where researchers are accustomed to teasing out frustratingly small statistical blips, these numbers represent something truly seismic.

It is important to note that the researchers did not identify this variation as a "depression gene." Rather, drawing the short genetic straw makes one susceptible to stress and its downstream effects (which may include depression). One also needs to have regard for the fact that not all depressions are caused by stress.

Think of the short allele as a "vulnerability gene." Those with the long allele, by contrast, may be regarded as the proud owners of a "resilience gene."

To further clarify the resilience factor, the depression rates for those with the long allele did not vary, regardless of whether they had experienced zero recent stressful events or four or more. Those with the short allele, by contrast, only experienced this same low depression rate as the long allele people when not exposed to any major stress, period.

As Dr Weinberger described it at a subsequent APA, this particular gene "impacts on how threatening the environment feels." Or, as his colleague Andreas Meyer-Lindenberg put it at yet another conference I attended, the short allele "impairs your ability to respond to what life throws at you."

Noted the Dec 19, 2003 Science: "Together, these studies suggest that the gene variant biases people to perceive the world as highly menacing, which amplifies life stresses to the point of inducing depression."

So, oddly enough, when the Freudian-inspired DSM-I of 1952 fingered "the stresses of interpersonal relations" as complicit in our behavior it was on the right track. Moreover, it wasn't far off in assuming that mental illness was the result of a maladaptation of the individual to his or her environment.

Where Freud's followers went wrong was in thinking that these "neurotic reactions" - to which they assigned a quasi-mystical quality - had little or nothing to do with the meat housed inside our skulls. But that is changing.

More later ...

Scott Gregory Hawkins - Update

Last week, I spoke out on the tragedy of Scott Gregory Hawkins, a transfer junior at Sacramento State, who was beaten to death with a baseball bat in his dorm room. Scott was a history buff who had hoped to become a history teacher or history professor. He was a religious individual who had volunteered in a number of activities to help others, including working with inner city kids, working on an Indian reservation on the Idaho-Nevada border, and working in a mission school in Chile.

Scott also had Aspergers, believed to exist along the same spectrum as autism. Among other things, individuals with Aspergers evidence severe difficulties in social interaction. According to one of his dorm-mates, Scott "wasn't the best socially" and "didn't have many friends." Nevertheless, "he seemed pretty normal to me. He was just shy. A very smart kid, though."

His father mentioned that his Aspergers "sometimes made him a target for bullies."

This update, from The Consumerist:

Not only did the UC Davis Medical Center send a $29,186.50 bill to the parents of college student who was beaten to death by his roommate, they also sent a letter letting them know that their son was considered indigent and was no longer welcome at the hospital if he needed further treatment. He doesn't, of course, because he is deceased.

Apparently he also had insurance, and the hospital should have sent the bill to his insurer. 

"I can't believe that in any country besides the U.S., any civilized country, that the parents of a murdered boy would receive this bill for $29,000 and such an insulting letter," Gerald Hawkins, the victim's father, told ABC 10 in Sacramento, CA.

The hospital has apologized.

Thinking With Our Meat

In my previous three blog pieces, I discussed how working on our own various personality issues and behavioral quirks loom large in our recovery. The last piece ended with the proposition that the mind and the brain may be an artificial distinction. To back up my point, I need to backfill the narrative with some brain science (from an earlier piece). Bear with me ...

If you're a serious researcher wanting to know more about your field, you don't waste your time attending the annual meeting of the American Psychiatric Association. The week-long meeting is largely regarded as a junket where clinicians can pick up the CME credits they need to remain in good professional standing.

But if you know what you're looking for, you can learn a hell of a lot. In eight years of APAs, I've had the honor of listening to three Nobel Laureates, plus numerous others who deserve a free trip to Stockholm. I particularly enjoy hearing the brain scientists, who are kind enough to dumb down their presentations for the psychiatrists, which means people like me can kind of follow along.

Here's how it works: When Daniel Weinberger of the NIMH is at the APA and happens to mention the COMT Val 108/158 Met variation (don't ask), he pauses to explain what that means. Not only that, he has cool PowerPoint slides that even psychiatrists and Geico cavemen can follow. When the same Dr Weinberger is at, say a schizophrenia research conference, addressing an audience that includes 2000 Nobel Laureate Arvid Carlsson, he doesn't even bother to let on what the COMT Val-Met variation is all about. He just assumes everyone knows. And forget about a cool PowerPoint.

Research conferences don't intimidate me. Remember, raccoons respect my piss. In San Diego in 2009, at the International Conference on Schizophrenia Research, I approached a table where very smart people were drinking their morning coffee, and introduced myself as the only C student at the table. The line worked so well I used it the rest of the day. It didn't take me long to get into the spirit of this particular conference, and soon I was referring to my coffee as my "neuro-cognitive starter."

Naturally, I knew exactly what to say to the likes of Dr Carlsson. Being a journalist, I assumed a totally professional demeanor and introduced myself as someone about to become a grandfather who would like to thank his son-in-law for his participation in the effort - who happens to be a neurosurgeon in training - if he (Dr Carlsson, that is) would be so kind as to provide an autograph.

Dr Carlsson, to his credit, smiled indulgently, and graciously signed the back of my program. His co-Laureate, Eric Kandel, did the same for me a few years earlier at the APA in Atlanta when I told him about my nephew who is as smart as Einstein. "I really admire your work," I burbled to Dr Carlsson, as my parting remark. I'm sure that was the high point of his life, coming from a C student.

A little background: Dr Carlsson discovered that dopamine was a neurotransmitter. Finding a new neurotransmitter was to brain science what the discovery of Uranus was to astronomy, only far more significant. At least, back in William Herschel's day, we knew what a planet was and what it did. By contrast, as late as the early 1960s, we had only the vaguest idea how brain cells - neurons - communicated.

So for Dr Carlsson to even arrive at the concept of neurotransmitter and dopamine, first he and his contemporaries had to figure out the Newtonian physics of that mysterious inner universe we call the brain.

We now take it for granted that a neurotransmitter is a packet of chemicals that is delivered from one nerve cell across a gap (or synapse) to another nerve cell. The neurotransmitter glutamate, for instance, instructs neurons to get excited. It's all about chemicals outside the brain cell setting off chemical reactions inside the brain cell (after first being assembled inside a different brain cell). Technically electricity is also involved, but we don't need to go there.

Had Dr Carlsson stopped right there, he certainly would have earned his plane ticket to Stockholm. (Wait, Dr Carlsson is Swedish - he probably only had to drive across town to collect his prize, assuming he could find a place to park.) But no, Dr Carlsson connected dopamine deficiency in the brain to Parkinson's, which led to L-dopa and other agents for its treatment, thereby significantly improving the lives of countless millions.

That isn't the end of the story. Dr Carlsson's discovery literally opened up the field of biological psychiatry, which posits that - hello! - the brain is not undifferentiated tofu. You can argue till the cows come about whether the mind and brain are the same or two entirely different entities, but when all is said and done, how we react to the environment around us and how we anticipate our future is mediated through the elegantly intricate processes of the meat housed inside our skulls.

We think with our meat. Newtonian meat, quantum meat, highly specialized units of meat, 100 billion cells - as many as the stars in the Milky Way - arranged in infinite connections switched on by some 16,500 genes out of a total of about 25,000 in the human genome.

So when I told Dr Carlsson I admired his work, I really meant it. Not only that, I was in awe of it. I would have felt the same way had I a chance to shake Einstein's hand. So - seriously - I didn't mind at all that I looked like a fool. Every day, when my very smart son-in-law is conferring with neurologists and prepping for surgery with a precious life hanging in the balance, he is literally performing his work in the very considerable shadow of Dr Carlsson. And now he has Dr Carlsson's autograph hanging from his wall.

So here was Dr Carlsson, in the audience at a schizophrenia research conference, listening to Dr Weinberger, part of a new generation building on his work. It didn't take researchers long to figure out that an oversupply of dopamine is involved in schizophrenia and that an emotionally and cognitively stable brain has a lot to do with dopamine in "just right" amounts.

But the brain isn't just chemical soup. It's not simply a matter of splashing in a bit of this and a bit of that into a bubbling broth. Cells organize themselves into extremely complex systems, which in turn interact with each other in unbelievably sophisticated and subtle ways. It's more helpful, instead, to think of the brain as a computer, or - even better - as all the computers in the world connected with each other through the internet.

We can also think of the brain as an ecosystem.

At its most rudimentary level, we are talking about the primitive and reactive parts of the brain communicating with the highly sophisticated thinking parts of the brain. In certain situations, if the communication is too efficient, irrational thoughts dominate the internal dialogue of the brain. In others, if the communication is inefficient, rational thoughts fail to get through.

The COMT Val-Met variation that Dr Weinberger was talking about is involved in this process. COMT is an enzyme that influences dopamine transmission in parts of the prefrontal cortex. From a treatment standpoint, a "smart" dopamine med that targets COMT to influence dopamine in a specific region of the brain may be a far safer and more effective way to treat schizophrenia and other mental ills than our current generation of meds.

I first ran across Dr Weinberger at the 2003 APA in San Francisco, in relation to a gene that influences a different neurotransmitter, serotonin. I was an innocent, about to have my eyes opened ...

Judging Amy - Follow-up

In my previous two blog pieces, I recounted the adventures and misadventures of the fictional Amy, who clearly evidenced personality issues that operated both to her advantage and disadvantage. My point was that before we congratulate ourselves in not being like Amy, it would be far more useful, instead, to acknowledge that we have a lot more in common with people like her than we would care to admit.

In short, we need to be thinking in terms of WE, rather than THEM vs US.

A lot of attention is paid to managing our illness - such as bipolar or depression or anxiety - but what tends to hold us back in life are our unresolved personality issues. I got to observe this close-up in my years of attending and facilitating DBSA support groups. I strongly suspected in some individuals an undiagnosed personality disorder in play, but more often than not I saw myself looking in the mirror at my own personal shortcomings.

We get fearful, we feel threatened, we get overwhelmed. We may flip out, we may become avoidant. We overreact, we under-react. In desperation, it seems, as a way of dealing with a world that seems to be increasingly aligned against us, we restructure our own reality. Call it Me World, where we are no longer hold ourselves accountable, or as accountable.

This may allow us to hold onto our sanity for a little while, but the catch is the real world doesn't buy into our reality.

What psychiatry categorizes as personality disorders sheds invaluable light on what is going on with us, but with this major caveat:

Personality disorders are by no means definitive. The DSM method of separating out and categorizing various personality disorders creates the misleading impression of identifying (and thereby labeling and stigmatizing) an individual by the so-called disease at the expense of understanding the person. The reality is different degrees of symptom severity and overlap, which the next DSM is likely to address, probably in the form of a "dimensional" schema to coexist with its categories.

Okay, now a quick traverse of the four best-known - and closely-related - personality disorders, which the DSM groups together as Axis II, Cluster B:

Borderline Personality Disorder

Freud's successors came up with this term to describe what they saw as problem patients bordering on psychotic. Emotionally unstable is a far more accurate description. Nevertheless, the label borderline stuck, together with the legacy of borderline individuals being regarded as problem patients. Sympathetic hospital staff have been known to turn on individuals in distress once they have been handed this diagnosis.

Borderline made its official debut in the DSM-III of 1980, but on the surface is very difficult to distinguish from bipolar. Unofficially, psychiatry is guided by the common stereotype of the moody and often hysterical teenage girl (or people who act like one) who may have abandonment issues, act impulsively, and engage in destructive behavior such as cutting. Twice as many females are diagnosed with the illness, possibly because problem males better fit the stereotype of antisocial personality disorder.

People living with someone who exhibits borderline tendencies typically describe the relationship as akin to walking on eggs: one minute all love and light, the next a hateful explosion or the sullen silent treatment. A borderline meltdown tends to have its roots in the individual’s lack of ability to handle the stress of any given social situation. Thus it can occur without warning. This tends to contrast with bipolars behaving badly, which typically flows in slower cycles.

Antisocial Personality Disorder

Serial killers generally fall into this class, but the diagnostic criteria is wide enough to include your abusive boss or scheming co-worker, or for that matter your brother who borrows your car and returns it without refilling the tank. According to the old joke, poor people with antisocial disorder are in prison, middle class individuals with this disorder are in therapy, and rich people with the label are CEOs. These are your classic sociopaths, out for number one, with no regard for others. “I’d walk over my own grandmother to re-elect Richard Nixon,” Watergate conspirator Chuck Colson once bragged. He wasn’t joking. He authored an “enemies list” of real and imagined political opponents to be singled out for special treatment, such as FBI harassment and tax audits.

Typically, men are three times more likely than women to receive the diagnosis, leading to a strong suspicion of gender stereotyping between borderline and antisocial. A female who is emotionally overwhelmed and angry may throw a hissy fit. A male in a similar state may throw a punch.

Narcissistic Personality Disorder

We are not simply talking about over-inflated egos. Rather, the narcissist sees him or herself at the center of his or her own personal universe, with everyone else relegated to bit players assigned to specific minor roles. Dare to intrude reality into this individual's fantasy world and brace yourself for a narcissistic rage.

Histrionic Personality Disorder

Most of us enjoy being the center of attention, but people like Tom Cruise tend to go about it by jumping on Oprah’s couch. Those inclined toward displays of excessive emotionality also hate it when the spotlight turns to someone else, even a loved one. “Poor me” may also feature in their routine.

Mind vs Brain

The DSM-I of 1952 interpreted behavior as "determined by inherent personality patterns, the social setting, and the stresses of interpersonal relations" and tended to give far less weight to "the precipitating organic impairment.” This separation of the mind from the brain had far-reaching effects. With the advent of biological psychiatry, personality disorders became the poor relation of psychiatry. The ground-breaking DSM-III of 1980 had the effect of highlighting "Axis I" illnesses such as bipolar, depression, schizophrenia, and anxiety (all with obvious biological underpinnings) at the expense of ghettoizing the personality disorders into "Axis II."

Of all things, biological psychiatry is rescuing personality disorders from past and current neglect. The "stresses of interpersonal relations," for instance, are turning up on brain scans in ways that are screaming, "major paradigm shift."

More later ...

Judging Amy - Part II

In Part I, we investigated a single blow-up during a funeral service in the life of the fictional Amy. Her meltdown could have been the result of a bad hair day. It could have been from a mood disorder. Or Amy could be dealing with unresolved personality issues. We are leaning toward the latter, but we need a lot more to go on than one unfortunate incident ...

Okay, let’s play spot the pattern with Amy: Has told mom 15 years running that she is six months from submitting her novel manuscript - her friends call it the next Wuthering Heights - to a publisher; Has had fights with everyone who has tried helping her get her manuscript published; Says she will join an exercise program once she has submitted her novel…

Okay, we’re starting to pick up a pattern. But is it one that seriously impairs her life? She already has a secure and well-paying job. What about other aspects of her life, then, such as personal relationships? Her Wuthering Heights manuscript steams with hot sex, which she broadly hints to anyone who will listen is autobiographical, but her last fling was twenty years ago. She has never sustained a long-term intimate relationship, but then again she manages to attract a lot of friends.

Granted, these friends may have to cut her a bit of slack, such as the time she abused and stiffed a waitress because she couldn’t order from the children’s menu. And they roll their eyes when she says she’s going to have her own show on the Food Network, but she’s just crazy enough to pull it off. After all, she’s a good friend of Rachel Ray’s, and she wouldn’t be saying that if it weren’t true, right?

Yes, Amy may have issues, but her ability to manipulate and intimidate and draw attention to herself, not to mention the supreme self-confidence she exudes, are exactly the right stuff for personal success. If only she weren’t quite so normal she could be on the cover of People magazine.

No, the real test is when she returns home to her empty condo, alone with her thoughts and vulnerabilities.

It’s later in the day, and the funeral party has gathered for eats in the church rec hall. Now Amy is making nice with the family. She tells her mother how good she looks and fusses appropriately over her three nieces. Okay, reaching for that second piece of cake after she just informed people of her diabetes may have raised eyebrows, but even cynical cousin Paula is flattered to hear they must “do lunch” sometime soon.

“I’m flying out to see a client tomorrow,” she lets everyone know, as if to apologize for her early exit. She doesn’t tell them that the “client” is really a Ponzi scheme artist out to separate her from her personal fortune. But the joke is on the Ponzi schemer. Little does he know that the personal fortune he has heard Amy refer to involves the film rights to her next Wuthering Heights, the one that has been in a state of near-completion for 15 years, the one that Steven Spielberg will be shooting any day now.

And I say to myself, what a wonderful world …

For the full version of this article on mcmanweb, please check out: Poisonality

Judging Amy - Part I

Following is a chopped-down version of the article, Poisonality, from mcmanweb:

Rewind a bunch of years ago. Bill treats his mom to a cruise.

Fast forward to the present. An aunt is being laid to rest. Bill's mom happens to mention the cruise to her daughter. As the casket is carried out, the daughter pulls her other brother aside and says in a voice quivering with rage, one that carries into the distant pews, “She really knows how to push my buttons!”

Everyone would agree that the daughter’s behavior is highly inappropriate, but is it consistent with a personality disorder? Consider:

Let’s suppose the daughter – call her Amy – had been especially close to her aunt and not so close to her mother. Suppose for two days, in her state of distress, she has been enduring a steady stream of sugar-coated insults from a mother she can barely stand. Then mom makes a seemingly innocuous comment that sets her off …

Let’s change the context. This time, suppose Amy had to cross three time zones to attend her aunt’s funeral. She has missed a night’s sleep which has triggered an irritable hypomania. During the service, she is literally crawling out of her skin. The air is oppressive, the people are making her claustrophobic, she can’t sit still, she wants to scream. Her mother says something, and she turns to her brother …

Distinguishing a bad hair day from a mood episode from a personality disorder meltdown is notoriously difficult. Even Mother Teresa had her off-moments, and no doubt Gandhi had unresolved issues he needed to work through. We all have feet of clay. Labeling someone with a personality disorder, then, is perhaps the most insulting and stigmatizing act one can visit upon an individual, even in the name of therapy and treatment. Reflect for a second the names psychiatry has bestowed on the four main personality disorders, lumped together into what are called Axis II cluster B personality disorders: Borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder.

You are not supposed to like these people, is the strong message attached to these labels. These people are poison, the message goes on to say. They lack empathy, they are impulsive, and only they matter. The golden rule doesn’t apply to them and neither do most of the commandments and other people's personal boundaries. Cut them out of your life, run away, treat them like lepers

Then again, if a family member or an acquaintance or a colleague at work is currently making your life miserable, you probably don’t have much sympathy. Life is like that.

Let’s return to Amy. She could be having a bad hair day. She could be experiencing a mood episode. She could also be having a meltdown stemming from various personality issues.

Please make careful note of the term, various personality issues. We are not going to attribute Amy’s outburst to one full-blown personality disorder. She may have one, she may not. But in all likelihood, a number of things are going on, a bit of this, a bit of that. Amy may be a kind and loving person, but her funeral theatrics indicate that something is clearly wrong.

But does Amy know it? She looks at the people staring at her and wonders what THEIR problem is, then leaves the church as if nothing happened. Or, if she acknowledges something has happened, she has already justified it – clearly it was her mother’s fault, the one who knows how to push her buttons. If her mother is a saint, if cornered, Amy will find a way to demonize her.

Woe to the person who may challenge Amy, but even if all her defenses are unmasked, she can still play the pity card. Even when she admits she’s wrong, the attention is worth it. There is victory in defeat.

Therein lies the difference between a person experiencing a bad hair day or mood episode and one with personality issues. The former are typically mortified by their out-of-character behavior (once they have settled down). When personality comes into play, the issue is far more complex. There may be no settling down; the behavior in question may be part of one's default setting (though change is possible). Or, there may be only a small window for remorse before Amy's world once again closes in on her, overwhelms her.

We all know people like Amy, but before you congratulate yourself for not being like her, it pays to recall that we all have personality issues of some sort. Besides, we need a lot more to go on than a single incident, more like a pattern.

To be continued ...

Misdiagnosis - Patients Tell Their Stories

I write a very different blog on HealthCentral's BipolarConnect. There, I take a backseat to my readers, bipolar patients and loved ones. Nearly a month ago, I asked them:

Were you misdiagnosed with depression or something else? How long did it take before you finally received the correct diagnosis?

Readers began telling their stories over the next days and weeks, which I assembled into three blog pieces. The narrative is sobering and instructional:

"Jane's" response is fairly typical. She was diagnosed with depression at age 16 and prescribed Zoloft, “which was making me like a bunny on mass caffeine consumption.” She was put on Paxil, but her depression worsened and she gained 40 pounds. Unable to hold onto her job, she found a new doc, who “cocked his head, asked about my family’s mental health history ... and asked me ‘Did anyone ever ask you if you thought you might be bipolar?’"

Finally, on Lamictal, she has her life back, but "I spent 11 years on the wrong meds and destroying my life because I was misdiagnosed.”

What is coming in loud and clear is that a misdiagnosis of depression is all too common, with years on antidepressants that only worsen one's unrecognized bipolar. Since we tend to seek help when we are depressed rather than manic, it is not surprising that we receive the wrong diagnosis at first instance. But then the problem is compounded by psychiatrists who refuse to listen. As "Rachel," who waited 14 years for the correct diagnosis, describes it:

My major complaint with this whole debacle is not that I was incorrectly medicated, it is that I was incorrectly medicated because an entire comprehensive mental and physical inventory was never taken. AKA no one ever TALKED to me about what I was feeling and why I was feeling it. No one had mined my data for facts and established a clear pattern of my behavior. The first person who did that was me. ... They didn't do their job. Much like getting a bad mechanic job, my tranny dropped out on the freeway and my vehicle hit the wall going 75 - a complete loss.

Doctors who don't listen - that has been by far the number one complaint I have received from readers ever since I began writing about bipolar more than 10 years ago. As "Lorraine," who suffered with antidepressants for three years, writes:

The doctor (as many are) was a know-it-all and rarely listened to me. The doctor rarely considered how I felt. The doctor thought no one could ever know more than this one. The doctor rarely even considered the possibility of what I was feeling.

Why does it take so long for doctors to get smart? "Georgine" responds: "I believe it was because I was diagnosed with [depression] before so instead of trying to find out what I needed, the docs took the previous diagnosis and just agreed with it."

It took 25 years before a doctor finally corrected the original error.

And this from "Eva":

It was only when I got old and ugly that a doctor finally said, ya man, she's depressed, and she's bipolar. ... When I was young, beautiful and well-groomed, I looked like a female high-powered executive. On top of the world to the doctors who saw me. They dismissed my claims of depression, as ridiculousness. What does she have to be depressed about? Now that I'm old, ugly, unfashionable, I'm believable.

Our own ignorance and denial is another factor. As "Lilly" reports: “I stayed in denial successfully with alcohol and pills.” At last, during her third hospitalization, “I finally opened up a pamphlet on bipolar.” She took her meds as directed, and “was able to see reason. ... I’ve been struggling with this disease for over 25 years since I had turned 16 years old and I was 40 when I excepted it as something I would have to live with and take care of for the remainder of my life. Life is good now.”

***

There is no substitute for listening to real accounts from patients and loved ones. You can check out the full conversation at Bipolar Connect in the comments to my original question and a follow-up question, as well as my three pieces and the comments to these pieces:

Misdiagnosis - Eight Readers Tell Their Stories

Misdiagnosis - The Dialogue Continues

Misdiagnosis - Readers Tell Their Stories