Mental Health Quiz: Test Your Knowledge

Every year, NAMI San Diego hosts a holiday pot luck dinner and annual meeting. For last night's gathering, I put together a quiz night and acted as quiz master. I compiled questions in eight categories. These are the questions I read out in the mental health category. Let's see how you do. Answers and commentary further below ...

1 What did John Adams, Abraham Lincoln, Theodore Roosevelt, and LBJ have in common?

2 The Priory of St Mary of Bethlehem, founded in 1247, later to become Bethlehem Royal Hospital for treating lunatics, is more commonly known by this name.

3 Hippocrates and the ancient Greeks referred to “the four humors” or "temperaments". One of them literally means "black bile." Name the temperament.

4 What did Christopher Columbus, Michelangelo, and Isaac Newton have in common?

5 Emil Kraepelin back in the early 20th century described a condition he called “dementia praecox." Today, we know dementia praecox by this name.

6 Between 1907 and 1939, more than 30,000 individuals with mental illness in the US were subjected to this procedure.

7 The 1949 Nobel Prize in Medicine went to António Egas Moniz for developing this treatment for the mentally ill.

8 NAMI was founded by parents who got sick of being blamed for their kids' mental illness. Psychiatry even had a label for these horrible parents. Name the label.

9 Robert Spitzer, the most influential psychiatrist you never heard of, is the man responsible for the modern version of this text, which we quote from all the time.

10 Eric Kandel, Arvid Carlsson, and Paul Greengard shared the 2000 Nobel Prize in medicine for their discoveries concerning "signal transduction in the nervous system." This is a fancy name for brain cells talking to each other. What's the scientific name for brain cell?

Answers

1 US Presidents with mood disorders. (A Duke University study reports that nearly half of the US Presidents had something diagnosable.)

2 Bedlam.

3 Melancholia. (The other three: Choleric, Phlegmatic, and Sanguine.)

4 Bipolar. (That's right, world. We give you the gift of civilization and how do you thank us? You marginalize us. Sorry we couldn't find America sooner for you, by the way.)

5 Schizophrenia. (Dementia praecox suggested a steadily deteriorating brain, but we know recovery is possible.)

6 Sterilization. (Those with mental illness were deemed a menace to the gene pool.)

7. The prefrontal lobotomy. (Some 40,000 lobotomies were performed in the US.)

8. Schizophrenogenic. (The label is as stupid as the reasoning behind it.)

9. DSM - Diagnostic and Statistical Manual. (A piece of fiction put out by the American Psychiatric Association.)

10. Neuron. (I have a theory that neurons only work with coffee. I hope I don't have to share my Nobel Prize money with anybody.)

Rerun: Coming to Terms

Yesterday, I posted a rerun piece to mark my four years living in Southern CA. To pick up where we left off ...

A thought-provoking Zen parable goes like this:

A man encountered a tiger in a field. He attempted to escape by lowering himself down a precipice. He looked down and, to his horror, saw more tigers looking up, anticipating their next meal. He looked up and spotted two mice above gnawing on the vine he was clinging to.

Oh, crap.

Then, looking to his right, he sighted a strawberry growing from the cliff face. Reaching over, he grabbed the morsel and popped it into his mouth.

“Mmmm!” he thought. “Delicious!”

***

My own translation: Enjoy the peanut butter.

By now I had all my stuff out of its boxes, and McMan International back up and running, which is my way of saying I had my desktop computer all plugged in and wired for internet. I had an email newsletter to get out, my first from my new world headquarters. I anticipated going full blast into the evening, but things went off without a hitch and I was unexpectedly through at about 2:30 in the afternoon.

Time to unwind with a walk. The winter sun was already low over the peaks behind me, and I was in the shadows, but the valley below me and the peaks in the distance were bathed in brilliant light.

I stopped in at the local coffee shop for a coffee and muffin to go. Shelley the proprietor heated my muffin for me and sliced it into tasty morsels. Soon, I was in the sun on the valley floor. The open space before me allowed my mind to breathe. Not too far off, peaks and rock formations rose from the valley like great cathedrals. I sipped my coffee, and munched on my muffin morsels, savoring the moment.

On my way back, I stopped at the general store, which adjoins the post office. Yes, we even have our own zip code. It was to be a dogs and beans night for me. Back outside, the sun had set behind the peaks and the temperature was dropping fast. I was back into my own shit now, still reeling from recent events, facing financial ruin, uncertain about my future, wondering how the hell I would ever get my life back together.

I hurried my pace, anxious to get home - home? - only to stop dead in my tracks. I looked right. The entire valley below was now in the shadows, as were the peaks and rock formations. But in the distance, a steep summit caught what was left of the sun full broadside. The mountain appeared to be radiating from the inside, a lustrous rosy glow that sharply contrasted with the cool hues of the darkened landscape.

Delicious!

Thank you, God, I found myself saying. I was experiencing the perfect moment, in the moment, what they call a Zen moment, fully aware, in the present. Tomorrow I could very well fall to pieces. But right now was a gift. Life happens here, right now. If you're second-guessing your past or fretting about your future, you're missing out.

The moment lasted maybe five seconds. Then I was back inside my own head, my own shit. But it wasn't the exact same shit inside the same head I returned to. I was back in my past, but it was one I could come to terms with. I was back in my future, but it was one I could face with hope.

Something similar occurred to me more than 30 years before, only back then it happened with the throttle wide open headed over the edge of a cliff.

We can all recall our exceptionally aware moments. Unfortunately, they tend to occur in highly-stressful and often life-threatening situations, such as skidding on glare ice at 60 MPH. This is when our fight or flight response takes over. The frontal lobes go off-line. We literally stop thinking as the faster-processing and more primitive regions of the brain (think amygdala) assume executive control.

Fight or flight is normally associated with an over-reaction, but here we are talking about a rare mental state that can only be described as calm awareness. If we had time to think about the dire straights we were in, we would probably panic. Instead, barring bad luck, we successfully avoid wrapping our vehicle around a tree. On one hand, the crisis is over in a micro-second. On the other, it’s as if time were slowed down.

There is a stretch of the Route 101 Coastal Highway in Marin County north of San Francisco that has probably washed into the Pacific by now. Gerald Ford was President and I had hair. I leaned my bike into the curves of the road, first one way, then the other, speeding up on the straightaways and gearing down on the hairpins perched high above the Pacific, my ears ringing with the roar of the waves crashing against the rocks below.

I was just leaning in for another sharp turn when I came upon some rocks that had worked their way loose from the hills above. There was no time to think. I swerved to avoid the obstacle and brought the bike around 180 degrees, but it was going backward toward the ocean on its own momentum. I felt the sickening sensation of the back wheel leaving the shoulder and losing traction in the soft earth behind. For a brief fleeting instant I had the sensation of being suspended in midair, like Wile E Coyote in those Roadrunner cartoons. Then the bike found purchase, jerked forward, and stalled on the shoulder.

I turned off the ignition, wheeled my bike to a safe place, and took stock. Something had shifted in me in those two or three seconds. Whatever had been holding me back before was holding me back no longer.

Within days, my life was on a new trajectory that would find me in New Zealand, attending law school, married, with a kid on the way. Now, here I was, decades later, in rural southern California. Healing happens, but don't expect to stay in the same place. There was no going back, not to New Jersey, not to my old sense of self. At the same time, I felt a sense of home. I was no longer on the run. I was here to stay. The land had heard my request. It was talking to me.

Rerun: Flying Home

Four years ago today, I found myself in Southern CA. I'm still here (though living in a different place). This piece from last year explains ...

October and November tend to be weird months for me. Early October, 2006 saw the publication of my book: "Living Well with Depression and Bipolar Disorder: What Your Doctor Doesn't Tell You That You Need to Know."

The book represented a major personal triumph for me, but life is seldom simple. It's amazing, in hindsight, how I didn't see it coming, but we never do. One day I was winding down from a round of book-related speaking engagements and radio interviews, making a mental note to pick up a Thanksgiving turkey, the next my marriage broke up.

I had been married (for the second time) for nearly three years, living in central New Jersey. On December 1, ten days after my break-up, I boarded a one-way flight to San Diego, wanting to sleep and never wake up.

I collected my bags and stepped outside the terminal. In the dark, I made out cruise boats in the brightly lit harbor and the silhouettes of palms. Under the circumstances, I could be forgiven for thinking I had set down in the middle of a holiday resort rather than waiting for my ride in an ugly airport. The balmy temperature lent to the illusion.

Paul drove up and I got in. San Diego Airport is located in the heart of the city. If this were New York, you would literally have planes taking off and landing in Central Park. I recall thinking how convenient this would be for me, that is until Paul got driving.

We got onto Interstate 8 going east and kept going. And going. Then civilization literally ceased. No lights no buildings, nothing. Surely, this had to be some kind of anomaly, I thought. Surely, some kind of satellite city would materialize, a St Paul, a Fort Worth, a Newark, even.

Meanwhile, I had the strange sensation of being airborne. Our wheels were on the ground, but we had gone from sea level to above 2,000 feet in the space of 30 minutes. Oh crap, I could only think, what have I gotten myself into?

At 3,500 feet we got off at an exit that could have featured in a slasher movie. Then we were in total darkness. My worst fears were realized. We were in the country. The country! Probably completely off the grid in a void where zip codes don't exist.

We got out of the car and I gazed up at the unfamiliar sight of stars in the sky, unbelievably bright stars, pristine in the mountain air, with nothing standing in the way of me and something billions of light years away, maybe only millions.

I woke up the next morning to a searing Van Gogh sun against a brilliant cobalt blue sky. Where there should have been a Walmart was a valley surrounded by 4,000-foot peaks. Time to check out my new neighborhood.

All the houses appeared to have be built out of box kite material, only not nearly so sturdy, seemingly wind-tossed at crazy angles. Oddly, though, the overall effect was harmonious, blending in with the rocky and hilly terrain. A straight line or level surface would have stuck out like a sore thumb.

A short walk and the houses gave way to horse farms. In contrast to the sky, the hues of the landscape were muted. The trees and vegetation here are testimonies to perseverance rather than abundance. Water is scarce, exceedingly so. Only the rocks flourish – boulders, outcrops, summits. The wind was blowing in from the desert and had a decidedly flinty tang.

Back in the old days, a wrong turn on a mule wagon spelled certain death. The Mexican border is about 10 or 15 miles away. These days, those seeking the American Dream are prepared to risk everything negotiating this treacherous northern passage.

I rounded a curve and suddenly I was the only person on this planet. Just me and splendid desolation. Any second, I expected to come across Buddhist prayer flags fluttering in the stiff breeze. Perhaps a wise Indian shaman who could tell me why the hell I was here.

Talk to me, land, I found myself saying. I felt a spiritual tug, but I was confused and out of sorts. I was badly missing the life I had just left behind, but I knew in my heart this was the place I needed to be. If any healing were to occur, it would happen here, in these mountains, where I could clear my head, establish a sense of perspective, and slowly come to terms.

But I had a major shock in store when I came back from my walk and inspected the pantry.

Hmm. Cans of refried beans (is there an air raid shelter out back?). Soup in packets (desiccated chemical nodules that no amount of super-heated water could ever satisfactorily dissolve). I mopped some beaded sweat from my brow. Rice-a-Roni, I read on one box. Something salty that claimed to be food on another. The type of cans you only see in food drives.

I already knew what was coming next. I’ve seen grown men cry over the sight, but my reaction is always one of anger and disbelief. How is such a thing possible in a world that gave us Shakespeare and Sophia Loren? I could only think. Why? But there is no logical answer to explain man’s inhumanity to man. Just the inscrutable wording on the box:

Ramen noodles!

“What a piece of work is a man! How noble in reason, how infinite in faculties, in form and moving how express and admirable, in action how like an angel, in apprehension how like a god! The beauty of the world, the paragon of animals! And yet, to me, what is this quintessence of dust?”

But I’m a highly-trained professional and it was time to take charge. In a calm and authoritative voice I told Paul and my other housemate: “Put your hands to your sides and slowly step back from the pantry.”

Don’t worry, I assured them, demonstrating to them that the skillet I had in my hand would be used for cooking real food, assuming I could locate some. But hey, I love a challenge. It's the one thing I have in common with Jesus - I've got the loaves and fishes thing down pat.

Life is about the little things. Several days later, seven FedEx cartons containing my life arrived at my door. By now, I had the food situation under control and was preparing a chili. Priorities are priorities. I ripped open the carton containing my kitchen gear and dived in for my zester. A minute later, I was in business. Zest-zest-zest – one peel to a lime into the pot, plus the juice. Now my chili had the missing zing and zap. Now I had a real chili going. A simple kitchen implement and suddenly I felt at home. My non-zester possessions could wait for later.

To be continued ...

My First (but By No Means Last) Experience with Online Dating - Conclusion

We pick up on the story in progress ...

Of all things, my brilliantly conceived plan of attracting the right woman based on my "Simon Cowell eliminator" involving the enigma of Einstein's iPod succeeded beyond my wildest dreams. There, mere hours after signing up was a message in my inbox. "Nancy," a classical musician who loved nature and ran triathlons for fun, had expressed interest in me.

Mind you, I had been too stupid to select her, myself. My prefrontal cortex, I learned too late, turned out to be a far better thinker than decider. To make a decision, it needed input from the emotional regions of the brain, and - alas! - my strongest emotion proved to be fear. That is, until I came across "Tomatoe Girl," a woman with no obvious interests who couldn't spell tomato but proved to be boneriffic.

Our only reason on earth is to make God laugh, and by now He was snorting milk out his nose. Here was the catch: Any future with Nancy in it demanded the same reaction in my brain as I had with Tomatoe Girl. Okay, it didn't have to be right away, but something had to happen. Sparks had to fly. Nancy clearly had soulmate potential, and her photos revealed a very lovely and thoughtful woman. But boneriffic?

We arranged to meet on Thursday for breakfast overlooking La Jolla Cove in San Diego. This was the mandatory "coffee date." She stepped out of her car, a vision of loveliness. She looked apprehensive and I assured her she didn't have to worry about passing any audition. We would be seeing more of each other, I let her know. She breathed easy, and the relationship was on. We began talking and couldn't stop. We continued our conversation along the beach, checking out the seals and other marine life. All too soon, it was time to go. We made a date to see each other Sunday.

We wound up at the end of the pier on Imperial Beach, sipping beer and eating fish tacos. The dolphins cooperated by putting on a show beneath us. So did the moon as we strolled the beach arm in arm. An attraction was growing.

Tuesday was to be a low-key date. Some afternoon outdoor recreation, then an early night. We rented a kayak and I amazed her by demonstrating I was not an out-of-shape spaz. Apparently, this sort of thing matters to triathloners, triathletes, whatever. Later, over beers on an outdoor patio, in the middle of one of our now-signature nonstop conversations, time froze. There she was, talking. Then, there she was talking in slow motion, with the sound muted. The patio and everything around her changed into a blur, and there was only her, just her. That was when it registered:

"Boneriffic!"

Suddenly, I was back in fast motion on a noisy outdoor patio with a mad urge to send glasses and plates crashing to the concrete as I took her in my arms and threw her on the table in a passionate embrace.

"Can we have a little privacy, please?" I would admonish the startled patrons.

A slow-motion camera on my face would have revealed an explosion of give-away micro-expressions that are visible in real time only to trained observers. For all I know, my eyes popped out of their sockets and my tongue rolled to the floor like a character in a Don Martin cartoon, but to everyone on the patio I was just a guy with his date, sipping beer.

I managed to maintain my sense of perfect equipoise all the way to her driveway. There, I lost my equipoise. Our relationship was about to turn romantic.

It stayed that way for three months, and it seemed like it would go on forever, but it didn't. One dark sleepy Monday morning, I walked out her front door. I didn't realize it would be for the very last time. Nothing left to say.

Previous installments
Part I
Part II
Part III

My First (but By No Means Last) Experience with Online Dating - Part III

The story so far: I had just signed up at on online dating site, only to discover my prefrontal cortex, which is nominally in charge of my thinking, had turned the assignment over to another part of my anatomy.

"Boneriffic!" my dopamine-sensitive ventral tegmental area (VTA) was screaming. For the purposes of this essay, all you need to know about the VTA is that this is the part of my brain where my dick has a branch office. As you will recall, I had worked out a brilliant strategy of making an intelligent choice from a long list of very good looking active and intelligent women based on my "Simon Cowell eliminator" that had to do with the enigma of Einstein's iPod.

Trust me, it was a brilliant strategy.

Then I discovered that my prefrontal cortex is only capable of weighing and measuring, but not deciding. For that, it needs input from the emotional areas of the brain. Unfortunately, my amygdala - fear central - was in league with my hippocampus and other centers of ancient memory, cranking out malicious sound bites for the amusement of my inner mother.

"Loser!"

Suddenly, I was that short skinny nerdy high school kid with glasses at my first high school dance, on the gymnasium floor, Bobby Vinton's "Blue Velvet" crackling out of a crappy PA system, trying to summon the nerve to ask Marie Kapinsky to dance.

"Loser!" my prefrontal cortex concurred, with unassailable prosecutorial authority. The brief it had assembled was bullet-proof. The men these women date, the thinking part of my brain reminded me, own their own homes. They drive in cars with Bose Surround Sound.

But I don't want to die a virgin! was my best defense. Okay, that wasn't exactly accurate, but I was stalling for time. In desperation, I summoned "Tomatoe Girl," the woman with no obvious interests who couldn't spell tomato.

"Boneriffic!"

Instantly, the tenor of the conversation changed. My dick was now in charge, with my VTA calling the shots. My amygdala and its henchmen were nowhere to be found.

She doesn't know how to spell tomato, my prefrontal cortex reminded me.

And that's why she won't complain when I show up in a car that doesn't have a working radio, my same (and now dueling) prefrontal cortex shot back.

Weighing, measuring, weighing, measuring ...

Nothing good ever came from thinking with your dick, my dueling prefrontal cortex let me know.

True, my dueling prefrontal cortex acknowledged. Bad marriages, failed relationships. I needed to change my pattern. In some way I couldn't comprehend but knew was true, Tomatoe Girl was part of my old pattern. On the other hand:

Who is the woman I want to be snuggled up with on the sofa right now?

Shit-shit-shit! This was crazy. The tide had turned. My entire prefrontal cortex was now in thrall to my VTA. Already, it was cooking up images of the two of us - me and Tomatoe Girl - curled up in a comfortable corner of her motor home (the corner that didn't need to be jacked up), sipping Jack Daniels from the same bottle and viewing reruns of "Dancing with the Stars."

"The sheriff won't show up till tomorrow," she whispers in my ear. "In the meantime, we have tonight."

I have a very good friend and mother confessor in LA, who I reveal all my dark secrets to. "Sometimes I want to drive down to San Diego and wring your neck," she is wont to let me know.

But it was no use. I was already composing a message that entirely contradicted everything on my profile. Hopefully Tomatoe Girl will just ignore me, I rationalized as I clicked "send." But I also walked away from my computer knowing I had broken the deadlock, that I had overcome my fear and insecurities and had set the process in motion. Tomorrow was another day.

Something told me to check my computer one more time. A fresh email informed me a new message was waiting in my online dating site inbox. She was a classical musician who loved nature and entered triathlons for fun. Not only that, she read the same books I did and had solved the enigma of Einstein's iPod.

"Holy shit!" I could only think. Could this be the one? 

To be continued ...

Previous installments
Part I
Part II

My First (but By No Means Last) Experience with Online Dating - Part II

The story so far: I had just signed up for an online dating site, but was having trouble making up my mind. We pick up on the action ...

By now, I was scrutinizing the photos with the intensity of a CIA analyst, desperately searching for visual clues, trying to give my brain something to work with. We are told that looks matter far more to men than to women. My answer to this is if I looked like George Clooney I wouldn't have to spend so much time thinking about what to put in my profile. Yes, looks do matter to men, but not in the way women think they matter.

A few years ago, I entertained (but not very seriously) the idea of starting up a new magazine, "Boneriffic." If we're going to have fake superficial standards for female beauty, I figured, then it made no sense that those who are incapable of getting it up for women should be the deciders. What dickless wonder, for instance, came up with the brilliant idea that vulnerable teen-age girls are supposed to mature into womanhood  with high-strung cadavers as their role models?   

It's not about physical dimensions or specs, and men know this. Women are their own harshest critics. Women: If you don't believe me, just listen to your own conversations. Trust me, if men said the same things about women that women say about women, there would be no new generation left on earth to even discuss the topic of sexual attraction.

You see a fellow member of your gender - a potential competitor in life's ultimate prize - and you say something like her eyes are too close together. We see the same human being, the manifestation of all things possible, and say it's a good day to be a bicycle seat.

It all comes down to the simple fact that men are wired to get boners, and for once Darwin and the Bible are in precise accord. So, back to my magazine, "Boneriffic." Real men, real boners. I would publish photos sent in by truck drivers of their sexy wives and girlfriends. Not only that, I would recruit these same truck drivers as designers for a whole new Boneriffic fashion line. Think Victoria's Secret meets LL Bean.

So, anyway, here I was, just signed up on my online dating site, my carefully plotted out strategy laid waste by the unexpected operational limitations of my prefrontal cortex. It could think, but it couldn't decide, not without some input from the part of the brain where emotions reside. Enter the midbrain's dopamine-sensitive ventral tegmental area (VTA). Rats whose VTAs get stimulated with an electrical current get erections and start mounting the nearest available female.

This is the part of the brain (the right VTA) that also lights up with humans in love, anthropologist Helen Fisher of Rutgers University reported in a lecture at the 2004 American Psychiatric Association’s annual meeting. (Simultaneously, the fear-mongering amygdala goes silent.) Romantic love, she went onto say, is a "drive" rather than an emotion, a "need" that compels one to seek a specific mate. Technically, testosterone/estrogen-driven lust (the craving for sexual gratification) is separate, as is oxytocin/vasopressin-influenced attachment (the sense of calm one feels with a long-term partner), but the three are also connected.

"Don’t copulate with people you don’t want to fall in love with," Dr Fisher cautioned, "because indeed you may do just that."

All kinds of emotions are in play, but they exist in relationship to the various drives, depending on how the eternal lust-love-attachment tango is playing out. The prefrontal cortex is also participating - assembling data, putting information into patterns, making strategies - but one gets the impression as a very junior partner. Case in point:

My brain was gridlocked. On paper, there was little to distinguish Prospective Soulmate #1 from Prospective Soulmate #2 from Prospective Soulmate #36. Which one? The mountain-biking attorney who loves to cook or the nature mystic small business owner who spends her time off raising autism awareness? Maybe it was the one who actually subscribed to - not just purchased as plane reading - "The New Yorker." But which one was she? The scuba diving emergency room nurse or the equestrian special education teacher?

I needed visual cues. The eyes have it - something that looked straight into my soul and locked in. A zillion and one things you can't explain, that would translate into a feeling or intuition, that would provide the prefrontal cortex with food for thought, that would help me make up my mind. I'd been at this since early afternoon and it was now approaching one in the morning. I'd set myself the modest goal of initiating contact with at least one prospect before going to bed and time was running out.

"Tomatoe Girl!" something in my head cried out. The one with no obvious interests who couldn't spell tomato. My prefrontal cortex had eliminated her in the opening minutes of the first round, but something in my midbrain was demanding a rehearing. Obediently, I dialed up Tomatoe Girl's profile and checked out her photos, and instantly felt a stirring below the equator. Oh shit, I could only think.

"Boneriffic!" my VTA was screaming. My poor prefrontal cortex didn't stand a chance.

To be continued ...  

My First (but By No Means Last) Experience with Online Dating

When my brain isn’t working, it’s a good thing I have a dick to think with. Case in point, some time ago I decided to give internet dating a go. I signed up on a site, then spent the next several hours agonizing over what kind of public face I wanted to display. For instance, would I come across as a snob if I said I read The New Yorker, and if I did let this particular cat out of the bag would I need to disclose that I wasn’t actually a subscriber but only bought it as a plane read?

And what if my soulmate-in-waiting pressed me on this? Then I would have to reveal that I’d only flown once this year, which meant my Scientific American reading was way down, as well.

Online dating is definitely a game of chess, calculating at least four moves ahead, using the best information available to anticipate a future that you have deluded yourself into thinking you can control. The part of the brain responsible is the prefrontal cortex, the seat of reason that separates us from those who believe that Fox News is true and other lower life forms.

But there are limits in our capacity to think things though, which I discovered once I started checking out the available women on this particular dating site. Just about all of them were very attractive. They looked after themselves, kept themselves fit, and did interesting things. Clearly, these women had no room in their lives for losers. What they wanted to hear from me was something along the lines of my love of the smell of the freshly oiled teak of my sun deck as I sat overlooking my private ocean while I broke down my last triathlon on the prototype iDrool that my good buddy Steve Jobs asked me to try out as a personal favor to him.

Fortunately, this culled most of the herd for me, but there were still way too many candidates to choose from. On one hand, I needed to come across as desirable as possible to the whole rest of the pack. On the other, I needed the equivalent of a prick like Simon Cowell to give me four finalists. My profile (which I have fictionalized here) was finally starting to take shape. First, the black box warning:

I'm self-employed, which means my boss is a cheap bastard and my employee a lazy no-good shit.

Then the catnip:

Silence is golden, so is great conversation. Sharing both with the right individual is priceless.

Then my set-up:

I'd love to prepare one of my gourmet pizzas for you ...

And finally my Simon Cowell eliminator:

... while we sip wine and listen to Einstein's iPod.

Perfect, I decided. More people on this planet have "Antarctica" listed as their place of birth than would be able to get what I was driving at by Einstein's iPod. Even I didn't know what the fuck I meant by Einstein's iPod.

It didn't matter. All I had to do was read through the profiles of some likely candidates, contact one or two at a time over the next several weeks, indicate my interest in them, and invite them to check out my profile. The first one who didn't impale herself on my Simon Cowell eliminator, assuming she was interested in me, would be my next coffee date. Let the games begin.

I went to the profiles only to discover my prefrontal cortex refused to cooperate. Shopping for women online is not the same as shopping for kitchen appliances online, or rather, yes it is. I may tell myself that I want a pasta maker that simply works on the same principle as an old-fashioned wringer washing machine, but ultimately I am going to choose the model that fires up my ventral tegmental area (VTA), the dopamine-sensitive region in the midbrain that mediates pleasure and reward.

While the thinking parts of my brain are weighing up customer reviews and performance specs and price points, my VTA is getting a hard-on over the shiniest looking appliance on the page. Through a complex series of brain signaling, the VTA shuts down the amygdala, associated with fear (which the thinking parts of the brain really need to be paying attention to) and starts negotiating with the prefrontal cortex.

Never mind price and practicality, says the VTA in effect. Get the bright shiny one. In a straightforward negotiation, the prefrontal cortex simply abdicates its authority to the VTA. (Yes, get the bright shiny one.) In a more complicated transaction, the prefrontal cortex spins somersaults rationalizing the choice already made by the VTA. (Yes, the bright shiny one is far better value for my money, even though it costs twice as much as the others. Not only that, it's far more efficient, notwithstanding the fact that three reviewers have noted they had trouble anchoring the object to the counter.)

Hopefully, when you unpack your shiny new pasta maker, the handle doesn't fall off. It probably doesn't matter, anyway. You'll use the thing just once, then exile it to the same dark corner of your lower pantry as your way cool retro bread machine.

So my best-laid plans for choosing a woman online were doomed from the start. This is why men get boners. Women, too, in a manner of speaking. The prefrontal cortex is simply incapable of making up its mind. Which woman? The tree surgeon who has just finished reading Joseph Campbell or the martial arts black belt who teaches drama at a community college? Or the woman with no obvious interests who enjoys her "tomatoe" plant?

As I said, good thing I have a dick to think with.

Rerun: Misdiagnosis - Patients Tell Their Stories

My recent five-part (and counting) series, Are Antidepressants Bad For You?, noted that a large part of the problem has to do with physicians blindly treating anything that resembles a depression with these meds, often with disastrous results. This piece from a year ago elaborates ...

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

Grading Depression

I recently posted a five-part (and counting) series, Are Antidepressants Bad for You? For a good many, the answer is yes. A lot of it has to do with our antiquated diagnostic criteria for depression, which treats virtually all depressions as the same. This encourages one-size-fits all treatments that turn out to fit very few and harm a good many.

In Feb, the American Psychiatric Association released a draft of an updated DSM, which would perpetrate the mistakes of the past. In light of my most recent series, it's appropriate here to re-run three of my critiques in this one post. Without further ado ...

Grading Depression - Part I

This is the first in a series of report cards that grades the homework turned in last week by the DSM-5 Task Force. Our first assignment: Depression.

First, some background ...

According to statistics cited on the NIMH website, major depression is the leading cause of disability in the US and affects 6.7 percent of Americans in any given year. Plus major depression is a major component to bipolar disorder, affecting another 2.6 percent of the US population each year. In addition, dysthymia (major depression lite) accounts for an additional 1.5 percent.

An illness of this dimension literally comes equipped with its own gravitational field. Thus, few psychiatric diagnoses make sense without some reference to depression, be it anxiety or schizophrenia or borderline personality disorder.

This means that if the people responsible for coming up with a new version of DSM depression get it wrong, then the whole document - together with the whole field of diagnostic psychiatry - is going to be out of alignment.

Fortunately, everyone knows what depression is, right? Um, not exactly. Early versions of the DSM recognized the highly complex nature of the illness at the expense of confusing just about everyone and thus influencing no one. The DSM-III of 1980 and its successors (the DSM-III-R, the DSM-IV, and the DSM-IV-TR) went for simplicity and clarity, which seemed to please just about everyone, except maybe patients.

The major knock on depression as we know it is that it is a catch-all diagnosis for all manner of things going wrong. But this is its major appeal, as well. One one hand, not enough patients are getting better on meds and therapies designed to combat this simultaneously mysterious and obvious entity called depression. On the other hand, just enough are.

At issue for the DSM-5’s Mood Disorders Work Group is how these major contradictions can be reconciled.

Time to start grading ...

The symptom checklist

This was a masterstroke from those who brought us the DSM-III. So much so, that we tend to think of the checklist as something that existed since before the dawn of time and that is based on pure science rather than being pulled out of thin air. Even though the current DSM recognizes several different forms of depression, everything originates from this (five of) nine-item menu.

Critics have identified a number of major problems with the list, namely:

• It is biased toward identifying depression in women rather than men (such as “appears tearful”).
• It fails to identify the patient’s predominant state of mind. For instance, it is possible to check off “feeling depressed,” followed by “significant weight loss,” “insomnia,” “psychomotor agitation,” and “fatigue.” Voila! Major depression, but what does that tell us? Is one vague mental symptom followed by four physical ones truly depression?
• It fails to identify the patient’s predominant state of mind (again). Sad? Agitated? Unmotivated? Feeling hopeless? Overthinking things? Excruciating psychic pain? Yes, we know it’s depression. But what is really going on?

On the other hand, the list has been in service for 30 years. It may not be perfect, but it does give us a reasonable approximation of a condition that so profoundly lays waste to so many. So why change it? This was the approach adopted by the workgroup.

Unfortunately, this was the safe option that gave us nothing to think about, that squelched a conversation that we badly need to be having, and that put the interests of monied stake-holders (such as the insurance industry) over the needs of patients.

Grade: F-minus.
      
Mixed Anxiety Depression

This is a wholly new and separate diagnosis, distinct from major depression. The workgroup recognized that nearly 60 percent of those with major depression also experience anxiety, which adversely affects patient outcomes.

The new diagnosis would acknowledge that one need not experience full-blown major depression or full-blown anxiety to wind up seriously distressed and incapacitated. A little bit of each will do. Thus, Mixed Anxiety Depression calls for just three or four depression symptoms (one which must include either feeling depressed or loss of pleasure), plus “anxious distress” which involves such things as “irrational worry.”

The recognition of anxious-depression is long-overdue, but since it was already listed in the DSM-IV appendix as deserving of future consideration, one cannot give the current workgroup credit for putting the issue on the table. Moreover, there is no mention of how “agitated depression” and other types of “mixed states” may fit into the picture.

Grade: C.

Mixed Episodes

The current DSM only recognizes mixed depression-mania states as occurring in bipolar I, and only in the ridiculously limited context of full-blown mania combined with full-blown depression. The DSM-5 would restore a measure of sanity by acknowledging that mixed states can occur in bipolar II, as well.

How this fits into unipolar depression is unclear. On one hand, the workgroup expressly rules out unipolar depression if the patient had ever experienced a mixed episode. On the other hand,
with no explanation, the workgroup adds the specifier, “with mixed features.” Huh?

There is good evidence that many individuals with unipolar depression experience mania/hypomania symptoms in their depressions, not enough to rate a diagnosis of bipolar, but enough to raise their levels of distress and make their depressions more difficult to treat.

On this very important issue, the DSM-5 workgroup has not handed in its homework.

Grade: Incomplete.

Grading Depression - Part II

Part I began issuing grades on the homework handed in last week by the DSM-5 Task Force concerning its proposed revisions to depression. To recap:

The symptom checklist - “So why change it? This was the approach adopted by the workgroup.” Grade: F-minus.

Mixed anxiety depression -  “The recognition of anxious-depression is long-overdue.” Grade: C.

Mixed depression-mania episodes - “On this very important issue, the DSM-5 workgroup has not handed in its homework.” Grade: Incomplete.

Moving on ...

Chronic and Recurrent Depression

These are two entirely different animals. For the first time, the DSM would fully acknowledge the chronic variety (“chronic depressive disorder” with an episode lasting at least two years). The new diagnosis would subsume dysthymia and change its threshold to include major depression as well as low grade depression.

Gone is the “chronic” specifier to a major depressive episode.

The DSM-IV criteria for recurrent depression would stand, namely two or more major depressive episodes (lasting at least two weeks) at least two months apart. No provision is made, however, for the reality of highly-recurrent depressions that come and go at a faster rate.

Recurrent depression - and the highly-recurrent variety in particular - may have more in common with bipolar depression than unipolar depression, or at least may occupy common ground in dire need of mapping. Somewhere, somehow, on some level, the rather obvious overlap between unipolar and bipolar needs to be recognized and dealt with. On this vital issue, the workgroup looked the other way.

Grade: F.

Severity

The DSM-5 Task Force mandated its various workgroups to come up with sophisticated severity measures analogous to assessing hypertension. This would obviate the rather arbitrary and clumsy distinction the current DSM makes between major depression and dysthymia (which the workgroup proposes eliminating).

It also places less emphasis on the symptom checklist. Thus, someone with all nine depression symptoms who is nevertheless able to hold down a job and keep his or her marriage going is in much better shape than someone with only four symptoms who technically does not meet the threshold for major depression but hasn’t been able to get out of bed in six months.

The Mood Disorders  workgroup is currently investigating a variety of measures.

Grade: Incomplete.

The Specifiers

The current DSM uses these to parse out different types of major depression, thus major depression with: psychotic features, catatonic features, melancholic features, atypical features, postpartum onset.

The DSM-5 would leave this list intact with two exceptions. “Chronic” is removed as a specifier and upgraded to a diagnosis, and “mixed features” is added with no explanation. In addition some changes are added to the psychotic features specifier to account for severity as well as type (“congruent” or “incongruent”).

The problem with specifiers in this context is they are only as good as the symptom checklist they are supposed to be specifying. There must be a better way, for instance, of distinguishing an agitated depression from a vegetative one or a mainly sad state of mind from one characterized by the lack of ability to care.

Think of depression as too much emotion on one hand and not enough on the other. Factor in too much or not enough thinking, and you can see that the experts charged with this brief had their work cut out them. They didn’t put in the work.

Grade: F.

Reactive Depression

The DSM-II of 1968 distinguished between what it saw as biologically-based depression (endogenous) and depression seen as a reaction to stressful events (exogenous). The DSM-III and its successors wisely ditched speculating about cause and effect and stuck to categorizing observable symptoms.

Thirty years later, however, advances in brain science suggest some merit in going back to the future, but with this ironic twist: Although current brain science does not yet support diagnostic descriptions based on underlying biology, one can make a good biological case for supposedly non-biological reactive depression.

Not only that, we already know that managing stress is a key to managing one’s depression. Stress Junction is where Freud, brain science, and common sense meet. The DSM-5 workgroup missed the bus.

Grade: F-minus.

Personality

Can persistent and treatment-resistant depression be looked upon as a personality disorder? Consider this assignment extra credit. Neither the Mood Disorders nor the Personalities Disorders workgroups took up the challenge.

No grade.

Grading Depression - Part III

NOS

Is there a place in your house you dread looking into? The attic? The crawl space? A certain closet? The bottom of your refrigerator? The current DSM contains its own version of the dreaded place. It is called NOS - not otherwise specified - and accompanies 41 listed diagnoses.

The draft DSM-5 would continue the practice. I peeked in and, suffice to say, experienced every traumatic flashback involving attics, crawl spaces, closets, and refrigerators, and then some. Some background:

If you’re a DSM editor and don’t know what to do with a certain type of symptom or behavior, you create an NOS closet (or refrigerator) and stick the weird stuff in and close the door. Maybe you’ll figure out what to do with it later.

It you’re a doctor and don’t know how to diagnose a certain patient, you write up NOS and find the appropriate closet (or refrigerator), shut your eyes, stick it in, and close the door. Maybe you’ll come up with the correct diagnosis later.

The trouble is NOS is a black hole. What, for instance, does “Depression NOS” mean? Imagine “Cardiovascular NOS” and you can see that the practice is unacceptable, whether one is practicing medicine or writing a diagnostic manual. Moreover, the practice is highly abused. A background paper put out by the DSM-5 mood disorders workgroup cited an unpublished study that found that the specialist and nonspecialist clinicians in the sample employed “NOS” in 37-38 percent of their primary diagnoses for depression.

The DSM-5 would change NOS to CNEC (conditions not otherwise classified). I opened the freshly painted closet door to find ...

Subsyndromal depressive CNEC. This would include patients in obvious distress who somehow don’t meet the formal diagnostic criteria for depression. Given the extremely wide view of depression the DSM already employs and its generously low thresholds it’s hard to imagine such a group. Certainly there are those who must put up with residual symptoms once the worst is over, but can’t we find a better way of defining this category? Out in broad daylight?

Major depressive disorder superimposed on a psychotic disorder. What the hell is something this major doing buried away in a closet?

Recurrent brief depressive disorder. So THAT’s where they stuck highly recurrent depression! I was looking all over for it. Nope, not out with recurrent major depressive disorder, where it belongs. Nope, not red-flagged as a type of depression closely related to bipolar. Nope, stuck away in a closet.

PMDD. Are you kidding me? We still hide “women’s problems” in the closet?

The sad thing is the things lurking in the DSM-5 CNEC closet are nearly identical versions of those still gathering dust in the DSM-IV NOS refuse bin.

Grade: F-minus

To Sum Up

Thus concludes my three-part DSM-5 Depression Report Card. Here are the subjects and my grades:

• Symptom Checklist: F-minus
• Mixed Anxiety Depression: C
• Mixed Episodes: Incomplete
• Chronic and Recurrent Depression: F
• Severity: Incomplete
• The Specifiers: F
• Reactive Depression: F-minus
• Personality (extra credit): No grade
• NOS: F-minus

Overall grade: F

Concluding Remarks

One of the ironies in issuing this report card is that I owe much to virtually all of the members of the DSM-5 mood disorders workgroup. I have read their articles. I have heard them speak at conferences. I have asked them questions face-to-face. In some cases, I found myself seated at the same breakfast or luncheon or dinner table.

My dealings with these individuals have been extremely productive and beneficial. To a person, they are as dedicated to their work as they have been gracious to me. Moreover, a good deal of what I know about mood disorders can be attributed to them and their colleagues. Many of my key Aha! moments are a direct result of the wisdom they have shared with me, their professional colleagues, and with patients and family members.

So, what went wrong?

For one, DSM-5 operating parameters were far too restrictive, involving an onerous burden of proof for new inclusions. Too often, the necessary empirical data was lacking. We may “know” for instance that depression is bound up in personality, but can we “prove” it?

Scientists need to “validate” their claims with scientific evidence. But what if the picture they produce is inaccurate and misleading and leads to the kind of absurd results I've brought up this series? No acknowledgment of the obvious relation and overlap between depression and bipolar? C'mon!

My concern is with "credibility," which the DSM-5 sacrificed in its obsessive over-pursuit of "validity." As a result, the DSM-5 is failing in its key mission of aligning psychiatric authority to our clinical reality.

Nevertheless, everyone has a stake in the status quo - Pharma, the insurance companies, the clinical-research establishment, perhaps even patient advocacy groups. Credible or not, the DSM pays the bills. Thus, no one is about to stand up and say the DSM-5 is a piece of shit. Okay, I just did, but who listens to me?

The other main problem is “paradigm freeze,” which I will get to in a future blog piece.  

And Finally ...

I don’t want to come across as negative, but my next Report Card grades bipolar, which will also involve liberal use of the sixth letter of the alphabet.

Are Antidepressants Bad for You? - Part V

We left off with the proposition that if you walk in the door with depressive symptoms, your clinician has at least four chances to get it wrong and only one chance to get it right. Your condition may be posing as classic depression, but may in fact be something completely different, namely:

• The depressive phase of bipolar.
• A highly recurrent depression, having more in common with bipolar than classic unipolar depression.
• A personality disorder, such as borderline.
• Your true personality - your "normal" baseline self - rather than an exception to your personality.

Chances are your clinician is missing this. He or she is thinking: Looks like depression, must be depression, ergo antidepressant. But we know that antidepressants can make bipolar worse. Likewise, there is good support for the proposition that people with highly recurrent depression need to avoid them, as well. And even a caveman's dumb half-brother knows that there is no med for changing a personality.

Clearly, most of you reading this should never have been put on an antidepressant in the first place. A placebo would have worked a lot better and with no side effects. At least you wouldn't be feeling worse. But maybe you're one of the "lucky" ones, with classic depression. An antidepressant for depression is just what the doctor ordered, right? Um, uh, define depression. This edited extract from a Feb blog post elaborates:

The DSM-II of 1968 viewed depression as both separate from (in the sense of “depressive neurosis”) and as part of manic-depression (in the sense of “manic depressive illness, depressed type”) and tied into anxiety (in the form of “involuted melancholia” and as the driving force of “neurosis”) as well as embedded into personality (as in “cyclothymic personality disorder characterized by depression”).

Moreover, the DSM-II distinguished between depression seen as a result of the mysterious biology of the brain (“endogenous”) and depression seen to be caused by a reaction to events (“exogenous”).

The DSM-III of 1980 replaced all that with a monolithic view of unipolar depression, separating it out from manic-depression and anxiety and personality and doing away with the endogenous-exogenous distinction. Instead, for the first time, we were treated to the famous and extraordinarily arbitrary nine-item symptom checklist.

In my book, "Living Well with Depression and Bipolar Disorder," I cite a 2004 article by Gordon Parker MD, PhD of the University of New South Wales in support of the proposition that this one-size-fits-all view of depression results in clinical trials that indiscriminately lump all patients together, with no regard to critical distinctions that may spell the difference between success and failure.

We know for instance that an SSRI such as Paxil gets 50 percent of patients with “major depression” 50 percent better over a period of about six weeks. This is good enough for the drug companies, who now have a license to print money, but what about the patients? Who wants a 50 percent chance of success? And who wants to be just 50 percent better?

What do we know about Paxil, anyway? Does it work better on a patient whose depression is marked by sadness? If so, is it possible to target this group of patients? Maybe then we would be seeing 80 percent of these individuals getting 80 percent better.

And try this on for size. Maybe a patient whose main feature is lack of motivation (about which the DSM has nothing to say) would benefit from something else, as would depression brought on by stress (the type of “exogenous” depression axed from the DSM-III). Maybe these drugs don’t exist. Maybe Pharma would be encouraged to develop them. As Dr Parker in a 2007 piece concludes:

Depression is a diagnosis that will remain a non-specific "catch all" until common sense brings current confusion to order. As the American journalist Ed Murrow observed in another context: "Anyone who isn't confused doesn't really understand the situation."

***

To tie this in a bow: It's not enough that a clinician accurately diagnoses depression, as the term is at best an umbrella designation, the way "infectious disease" is an umbrella designation. Yes, an antibiotic may be useful against many types of infectious disease, but we cannot make the same claim for an antidepressant for the zillion different things going on inside our brains that we happen to lump together as depression. The best we can say for antidepressants is that they work for some individuals with DSM depression. The catch is we don't know in advance who these people are.

More to come ...

Previous articles

Are Antidepressants Bad for You?
Are Antidepressants Bad for You? - Part II
Are Antidepressants Bad for You? - Part III
Are Antidepressants Bad for You? - Part IV