Rerun: Lessons From Basketball: Outcome vs Process

With Final Four weekend coming up, it's time to revive my one basketball blog. Enjoy ...

Sunday's New York Times Magazine feature, The No-Stats All Star, by Michael Lewis, was nominally a piece about Shane Battier, who plays "small" forward (he's only 6' 8") for the Houston Rockets. On paper, Battier looks like an also-ran, with obvious weaknesses to his game and underwhelming stats.

Funny thing, though, when he is on the floor, his team scores more points than the opposing side. This season, Battier is a plus-10. A good player is a plus-3. Battier has a way of making his other teammates better by creating situations that statistically improve their chances of success. His specialty is creating bad nights for the opposing team, in particular their best shooter.

Sports has been experiencing a revolution in statistics - with the introduction of new measures for a player's performance - which in turn is changing how various front offices seek out talent and configure rosters. For instance, baseball, which started the trend, is now giving much greater weight to a batter's on-base percentage (ie the ability to get to first base, such as by drawing walks as well as getting hits).

Now basketball is beginning to catch on. Battier's forte is to force opponents into taking low-probability shots. For instance, if a shooter likes to turn left, he will force the opponent to turn right. Even if Battier scores zero points, if he can keep the other team's star shooter to say 25 points instead of 35, then Houston is likely to win.

Nevertheless, NBA insiders and players fail to perceive Battier's merits. If a superstar has an off-night against Battier, no one gives him any credit. The superstar simply had a bad day at the office.

The article zeroed in on a recent game against the Lakers. Battier would be guarding Kobe Bryant that night. On the pregame show, the co-hosts scoffed at the notion of Battier shutting Kobe down. Said Chris Webber: “I think Kobe will score 50, and they’ll win by 19 going away.”

Here's where it gets interesting. The article made a distinction between "process" and "outcome." The outcome, basically, is out of your hands, but you can control the process. All night, Battier kept forcing Kobe into low-probability shots. Late in the game, in frustration, Kobe drew a technical foul. That was the process - Battier was in control.

But should a low-probability shot hit its mark anyway - that is the outcome. You can't control that. If you have mastered the process, chances are you will achieve favorable outcomes. But if the outcome doesn't go your way, there is no sense in beating yourself up.

I suppose you can put it like this: Say you want to lose ten pounds. Ten pounds is the intended outcome. The process would be rigorously sticking to a healthy diet, exercise, and other routines. If you do that, losing ten pounds is doable. Most of us, though, fail at the process level.

But a good many dieters do everything right, and still the weight refuses to come off. Very frustrating, but if we had been true to the process, we can hold our heads high.

I've met a lot of patients who do everything right. Still, the depression, the anxiety, the agitation - you name it - persists. Extremely frustrating.

I've also met patients whose lives are in complete violation of the process. Not surprisingly, they are stuck in their recovery. Yes, a favorable outcome may be out of reach, but you will never know that until you have given the process your best shot.

Back in Houston, the game came down to the closing seconds. Kobe had the ball 27.4 feet from the basket. Instantly, Battier was all over him like an extra layer of clothing. As the article explained, Kobe misses 86.3 percent of the time when taking 3-pointers from beyond 26.75 feet at the end of very close games. And tonight, Kobe had to do it blind, with Battier's mitt up against his eyes.

He shoots, he ...

Here is Michael Lewis' closing paragraph:

It was a shot Battier could live with, even if it turned out to be good. Battier looked back to see the ball drop through the basket and hit the floor. In that brief moment he was the picture of detachment, less a party to a traffic accident than a curious passer-by. And then he laughed. The process had gone just as he hoped. The outcome he never could control.

Join My NAMI San Diego Walk Team

Last year, I joined the board of NAMI San Diego. Most of us are aware of NAMI and what it does. Whether you live in San Diego or Cincinnati, chances are you or a member of your family has contacted your local or state NAMI seeking information or support.

I know my family did when I went into crisis in Connecticut 11 years ago. I also know it brought my family peace of mind.

Since then, I have been peripherally associated with NAMI. I’ve attended conferences and fundraisers, I’ve spoken to various local groups, I’ve contributed pieces to their publications and websites. Then, last year I rolled up my sleeves and got involved.

Anyway, NAMI San Diego has its annual walk coming up on April 17th in Balboa Park. As well as being our biggest fund-raising event of the year, it also sends a strong message to the community. Here’s the deal:

I’ve formed my own walk team, McMan’s Silly Walkers. Those of you living in southern CA are cordially invited to join me. Be there, be square, be silly. Sign up and get your friends to sponsor you. For info on joining my team, check out my Team Walk Page.

For those of you interested in sponsoring me, you can go to my Personal Walk Page and make an online donation. Trust me, you have my personal word that this is money very well spent.

Also, location is not an issue. Yes, I encourage you to contribute to the NAMI in your locale, as well. But if you support the work I do here, I also encourage you to show your appreciation by sponsoring me on my NAMI San Diego Walk.

Go to the NAMI San Diego website for more info.

Rerun: Breaking News: Psychiatry Comes Up With New Diagnosis of Asshole

A Knowledge is Necessity exclusive.

In a surprise move expected to be announced shortly, the American Psychiatric Association's Task Force responsible for overseeing the revision of the DSM - psychiatry's diagnostic bible - has come up with the new diagnosis of "Asshole."

Unlike other disorders, episodes, types, and specifiers listed in the DSM, the diagnosis of Asshole fails to mention any symptoms. Nor does it offer a description of the illness.

"Let's put it this way," said E Pontius Paella MD, director of the Darwin Awards Treatment Center at Johns Hopkins and member of the working group that came up with the new diagnosis, "you know one when you see one."

The new diagnosis is the result of heated discussion throughout the Task Force's many working groups, in particular the one responsible for updating the bipolar diagnosis. According to bipolar group member S Belinda Humphries MD of the University of Northern South Dakota, speaking strictly off the record: "We were sick of hearing from our bipolar patients about the bad rap they were getting as a result of Assholes who had mistakenly been diagnosed as bipolar."

Leading bipolar patient advocate Phil Toogood was ecstatic over the news. "It's about time," he commented. "Since the dawn of history we've been putting up with their shit. Every time someone does some asshole thing, people automatically assume the jerk must be bipolar. Maybe now the public won't confuse us."

It isn't just bipolars. Reports Charles Manson from his prison cell: "For years, assholes have been giving us sociopaths a bad name."

The illness is considered chronic and untreatable. When asked to give an example, Dr Paella commented, "That's easy. Rush Limbaugh. Say no more." Dr Paella did add that Assholes can go on to lead productive lives. "Look at all those idiot commentators on Fox News," he observed. "See, there is hope."

When advised that not every Asshole can aspire to a position on Fox News, Dr Paella replied: "No problem. They can always become antipsychiatry bloggers."

The new diagnosis of Asshole is expected to become official in 2013, when the American Psychiatric Association is scheduled to publish the fifth edition of the DSM.

Rerun: 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.

Busy Day for Batty

Lily Pads!

Yesterday, Balboa Park.

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part III

Thus far (in Part I and Part II), I have kept what I refer to as “cycling illness” simple. As long as we appreciate that down and up are connected as different phases in the same cycle, there is little room for confusion. But there is a major complication called psychosis. If the psychosis is severe enough and prevalent enough, suddenly clinicians are faced with some very tricky diagnostic calls.

The current DSM recognizes psychosis as an illness in its own right and acknowledges its occurrence in other illnesses, including depression, bipolar, and schizophrenia, not to mention the hybrid diagnosis of schizoaffective. In theory, clinicians have a rough guide to work with. In practice, uncertainty prevails, namely:

How, precisely, does psychosis tie in to mood? And, while we’re at it, is there actually one person in the whole wide world who can explain schizoaffective, much less the reason for its existence?

Brain science and genetics promise to yield far more definitive answers than we presently have, which may explain why the draft DSM-5 changed virtually nothing. My view is we need to do our best based on the knowledge we have now, even if future scientific discovery proves us wrong. Let’s get to work:

The current DSM treats “with psychotic features” as a specifier to bipolar rather than to depression or mania. Let’s keep the specifier approach, but find more precise applications, thus:

Euphoric Mania with Psychosis

Various euphoric mania characteristics (such as enhanced positive abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as a superman on a special humanitarian mission).

Dysphoric Mania (Mixed) with Psychosis

Various dysphoric mania characteristics (such as enhanced negative abilities) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself or his or her situation in a grossly exaggerated light (such as the only one in the world aware of a vast conspiracy).

And a copy and paste from the Alternative Depression Diagnosis Part II:

Vegetative (or Mixed) Depression with Psychosis

Various vegetative domain characteristics (such as excessive guilt) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as deserving of punishment (such as being tracked by agents for an imaginary crime).

Agitated (or Mixed) Depression with Psychosis

Various agitated domain characteristics (such as a sense of exaggerated bad luck) may manifest as delusional thinking or hallucinations, in which the subject may see him or herself as the object of unwarranted harassment (such as being tracked by agents as a result of a frame-up).

***

Thus, in these situations, psychosis is strongly linked to different phases of the cycle in terms of both timing and congruency. When the mania recedes, for instance, so does the psychosis. This suggests mood stabilizers as a first option rather than an antipsychotic.

If, on the other hand, the psychosis appears have a life independent of the cycle, then the clinician needs to spell it out, such as: “Cycling l, with Co-Occurring Psychotic Disorder.” (The current DSM lists “Delusional Disorder” and “Brief Psychotic Disorder”.)

This suggests different treatment options, such as an antipsychotic for the psychosis plus a mood stabilizer for the cycle (with perhaps the antipsychotic serving double duty in lieu of a mood stabilizer).

It is important to emphasize that psychosis with a life of its own is not synonymous with schizophrenia. Generally, more is going on with schizophrenia than just psychosis. Nevertheless, a very compelling case can be made for an overlap between bipolar and schizophrenia. Unfortunately, the DSM’s ‘tweener diagnosis of schizoaffective is more of a problem than a solution. Thus:

Kill the Schizoaffective Diagnosis

The operative phrase to the schizoaffective diagnosis is: “There is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia.”

Criterion A lists other symptoms besides psychosis, and calls for a minimum time of one month. (There is a Criterion C for schizophrenia, which mandates a six-month minimum for “continuous signs of the disturbance,” but there is no reference to this in the schizoaffective diagnosis.)

Schizoaffective, then, is basically short-form schizophrenia punctuated by relatively brief overlays of depression or mania (the DSM minimum for mania, for instance, is one week). The assumption is that it is highly likely that there will be long periods when the schizophrenia symptoms manifest with no mood symptoms, and indeed this is a DSM requirement.

Thus, schizophrenia symptoms can appear without mood symptoms, but mood symptoms can’t appear without schizophrenia symptoms.

Does this sound like schizophrenia to you? Short form or not? Say, schizophrenia with mood symptoms? Is schizoaffective, then, a euphemism diagnosis for clinicians too chicken to tell their patients the truth? It appears that way.

Let’s kill the schizoaffective diagnosis, then. And while we’re at it, let’s rethink schizophrenia, complete with a name that accurately describes the illness. But that’s for later, along with a full review of psychosis. In the meantime, to sum up:

1. When the psychosis can be linked to a phase of the cycle: Specify the phase within the cycling diagnosis.
2. When the psychosis appears independent of the cycle but does not meet criteria for schizophrenia: Stick to cycling diagnosis, with a co-occurring psychotic disorder.
3. When the psychosis appears related to schizophrenia: Go with a schizophrenia diagnosis, with a mood symptoms specifier.

Please note that I do not regard this draft as anything approaching the final word. If you have your own approach to breaking down psychosis, or can think of a hybrid bipolar-schizophrenia diagnosis that makes sense - or for that matter can make a good case for not fixing what ain’t broken - then, please, let’s hear from you.

Iris Chang, An Appreciation

A brief note in appreciation of Iris Chang, who was born yesterday in 1968. Ms Chang is the author of The Rape of Nanking (1997), which documented the atrocities visited on the Chinese by the invading and occupying Japanese Imperial Army beginning in 1937.

In a very short space of time, in one locale, hundreds of thousands of civilians were rounded up and killed in indescribably horrific ways, and up to 80,000 women raped.

Ms Chang was motivated to investigate after hearing personal stories from her grandparents and after attending a seminar in 1994. Unbelievably, no one had bothered to write a book in English on what had happened. Two years of total immersion in the project followed. According to Ms Chang, she was ...

... in a panic that this terrifying disrespect for death and dying… would be reduced to a footnote of history, treated like a harmless glitch in a computer program that might or might not again cause a problem, unless someone forced the world to remember it.

The book was hailed as a journalistic and scholarly tour de force, with many honors accruing to its author, including National Woman of the Year from the Organization of Chinese Americans. Predictably, she was bitterly attacked by ultranationalist Japanese groups in denial, and by attention-seeking nitpicking scholars too lazy to research and write their own account.

To date, Japan has refused to apologize for the holocaust.

I confess to never reading the book, nor, with my tendency to spin into runaway depression, am I likely to. Last year, however, I did view a documentary based on her account. It’s a story that needs to be told and retold, that we need to hear and re-hear.

Ms Chang followed up with 2003 book on The Chinese in America. In Aug 2004, while on the road promoting her book and working on her next book about the Bataan Death March, she suffered a nervous breakdown and was hospitalized for three days with “reactive psychosis.” Over the months, she was beset by depression and was taking mood stabilizers.

In November, by the side of a road in rural California, Ms Chang aimed a revolver at her head and pulled the trigger. She left three suicide notes. She was 36.


Thanks to my friend David Kincheloe for the heads-up. You can read the post on his blog here.

Scenes From the Desert Canyon

Anza-Borrego Desert, Friday.

The People’s DSM: My Alternative Bipolar (Cycling) Diagnosis - Part II

As opposed to depression, a highly-complex illness that clinicians dangerously over-simplify, one can make a strong case that bipolar is far more simple than it looks. Change the name to “cycling illness” characterized by “phases” rather than “episodes” or “states,” borrow what’s relevant from what we already have for depression, fill in the blanks with a little bit about what “up” looks like, and stop right there.

Indeed, my first installment did just that. When stripped to essentials, cycling illness is basically a pattern of down and up. And since we tend to be down way more than we are up, it’s fairly accurate to say that cycling illness is depression with speed bumps.

“Up” is anything that contrasts with down. You don’t have to be dancing on tables. “Normal” or “better than normal” will do, so long as it shows you have a depression that is not standing still.

Complex depression, simple illness. Simple, really.

Okay, “up” needs to be explained a lot better than what you find in the current and highly antiquated DSM mania/hypomania symptom list. You can have racing thoughts, grandiosity, pressured speech, and all the rest, but are you feeling great or feeling lousy?

The DSM doesn’t tell you. Can you believe it? Myth has it that we’re supposed to be feeling like Leonardo DiCaprio with Kate Winslet on the bow of the Titanic (or vice-versa), but too often we’re more like Kim Jong il on a bad hair day.

Depression with a power surge, in other words. “Dysphoric” mania/hypomania, as opposed to “euphoric,” which I laid out in full in Part I.

Another way of looking at it is our depressions and manias are mixed. Hence the need for this Part II exercise. Think of dysphoric mania/hypomania as the cycle gone crazy - out of phase, so to speak - with both up and down screaming for attention at once. One is crashing down the door while the other hasn’t yet left the building.

How much depression inside mania/hypomania do you need? Only enough to turn euphoric mania/hypomania dysphoric. No need to count symptoms. Simple. Do we even have to add the specifier, “mixed,” to dysphoric? No. It’s totally redundant. Then again, maybe we better, thus:

1. MANIC PHASE, DYSPHORIC (MIXED)
2. HYPOMANIC PHASE, DYSPHORIC (MIXED)

Meanwhile, over on the other side of the diagnostic divide, we already have “agitated (or mixed) depression with mania” (which we would include on this side of the divide, as well, without specifically having to spell it out). In some cases agitated depression may appear difficult to distinguish from dysphoric mania/hypomania, but, hey, this is life in the real world. Depression and mania co-exist on the same spectrum, and, contrary to what the current and future DSM would have you believe, the two overlap. One bleeds over into the other. They don’t separate for the convenience of clinicians in a hurry.

Finally, what about situations involving say just two symptoms of mania combined with just three symptoms of depression? Going by official DSM criteria, you are healthy. Except for the fact that you are feeling rotten. Fortunately, The People’s DSM is not anal about symptom counts. Problem solved.

Dare we get more complicated?

Coming soon: We get more complicated. In the meantime, your feedback is strongly encouraged. Comments below ...