The Cortical Factor

I just finished viewing Lecture 18 in a 25-part video series by Robert Sapolsky of Stanford. Dr Sapolsky is to human behavior what Carl Sagan was to astronomy. There is no one better at explaining the topic to the general public than this man. It’s not even close. I first stumbled into Sapolsky in early 2003 and I’ve been something of a groupie ever since.

The video series I am watching is an actual undergraduate course in human behavior. I was looking forward to blogging on various highlights once I’d completed the series, but Lecture 18 represents the best exposition I’ve ever come across concerning how different parts of the brain talk to each other, so let’s get straight into it ...

Lower mammals have an olfactory hotline to the amygdala, the part of the brain in the limbic system that mediates fear and arousal and kickstarts fight or flight. Furry creatures are literally primed to react when they smell something funny. Mammalian limbic systems are standard issue for humans, except ours are wired to respond mainly to visual stimuli.

Ordinarily, the cortical areas of the brain are responsible for visual processing and sending info to the amygdala, but we don’t always have time to wait. There is a short-cut in the brain through the lateral geniculate (LG). The trade-off is that this information is less accurate. We’re more likely to make mistakes. As Dr Sapolsky explains, there is now strong evidence that this pathway is hyper-excitable in those with PTSD.

According to Dr Sapolsky, the frontal cortex should be regarded as part of the limbic system. Its role, essentially, “is getting you to do the harder thing when it’s the right thing to do,” as in behaving appropriately. Below is a screenshot of Dr Sapolsky illustrating in a very simple way two contrasting neural circuits. The circuit on the left has more axonal inputs going into its target neuron than the right. This makes it easier to activate this particular neural pathway.

But what if this pathway represents doing the wrong thing? To offset this, the frontal cortex essentially massages both circuits, inhibiting the left and biasing (rather than causing) excitation in the right. To accomplish enhanced excitation, the frontal cortex gets a boost from dopamine via projections shooting out of the ventral tegmental area and nucleus accumbens. Dopamine acts as the fuel in goal-directed behavior.

One illustration of doing the harder thing would involve reciting the months backward. The frontal cortex needs to be on its toes in processing the task, but those with damage in this area may have trouble over-riding the more habitual forward-recitation response.

Over time, learned behavior becomes automatic and gets stored elsewhere in the brain. Thus, someone with Alzheimer’s may not know what decade it is but still knows how to knit. This brings us to the famous example of Phineas Gage.

According to Dr Sapolsky, they take away your neurobiology license if you fail to mention this guy. In 1848, while tamping down blasting power during the construction of a railroad line, the powder exploded, sending the tamping rod through the side of Gage’s skull and out the top, taking out his left eye and emptying out most of his frontal cortex. (See top left image.) Amazingly, because the rod cauterized his blood vessels, Gage was able to get up and walk a mile-and-a-half to the nearest doctor.

Gage achieved a partial recovery, but experienced major problems controlling his behavior, leading his physician to conclude that this part of the brain “reins in our animal energies.” Interestingly enough, about a quarter of those on death row have a history of concussive trauma to the head.

Doing the harder and right thing tends to involve delaying gratification and not giving into temptation. Consider the m&m test. You hold five morsels in one hand and one in the other. The rule is you reach for five you get one, and vice-versa. People with cognitive impairments, even knowing the rule, may still reach for the five - they just can’t help it.

Lack of cortical input explains why our dreams make no sense. In REM sleep our frontal cortices are at their least active. That’s why in our dreams we do all sorts of things we would never want to do in real life. Thank heaven we're merely dreaming. Imagine, if we did some of that stuff in while awake. Oops - sometimes we mess up, and we find ourselves living with the consequences.

Much more to come ...

Epigenetics and Mental Illness and You

Two posts ago, I took Robert Whitaker to task for misreporting an NIMH-funded study in order to advance his own idiosyncratic agenda. Whitaker reported the study as a garden variety postmortem exam of brains of those with schizophrenia vs controls. The study, in fact, involved epigenetics, which Whitaker both failed to mention and displayed no knowledge of.

I first came across the field in late 2003, which I reported soon after in an email newsletter and a month or two later in an article on mcmanweb. Last year, I folded the piece into a reworked article on genes. Back in 2003, like just about everyone else, I treated epigenetics as a sideshow - worth knowing about but not worth missing the latest American Idol over. Now, it is abundantly clear that epigenetics is emerging as the main event.

Lately, I've been running across reminders that I need to put a match to all my website content on genetics and start over, with epigenetics front-center. Great, a mammoth science project. In the meantime, here is my original piece ... 

The conventional wisdom on genes goes something like this: DNA is transcribed onto RNA, which form proteins, which are responsible for just about every process in the body, from eye color to ability to fight off illness. But even as the finishing touches were being applied to the sequencing of the human genome (completed in April 2003), unaccountable anomalies kept creeping in, strangely reminiscent of the quarks and dark matter and sundry weird forces that keep muddying the waters of theoretical physics.

Enter the science of epigenetics, which attempts to explain the mysterious inner layers of the genetic onion that may account for why identical twins aren't exactly identical and other conundrums, including why some people are predisposed to mental illness while others are not. Scientific American devoted a two-part article to the topic in its November and December 2003 issues. To summarize:

Only two percent of our DNA - via RNA - codes for proteins. Until very recently, the rest was considered "junk," the byproduct of millions of years of evolution. Now scientists are discovering that some of this junk DNA switches on RNA that may do the work of proteins and interact with other genetic material. "Malfunctions in RNA-only genes," explains Scientific American, "can inflict serious damage."

Epigenetics delves deeper into the onion, involving "information stored in the proteins and chemicals that surround and stick to DNA." Methylation is a chemical process that, among other things, aids in the transcription of DNA to RNA and is believed to defend the genome against parasitic genetic elements called transpons. A 2003 MIT study created mice with an inborn deficiency of a methylating enzyme. Eighty percent of these mice died of cancer within nine months.

A late 2003 PubMed search of epigenetics and bipolar disorder revealed but two articles. A Jan 16, 2011 search turned up 83. Arturas Petronis MD, PhD, of the University of Toronto authored both of the 2003 articles. In one of them, he filled in some of the blanks:

We know that there is a high concordance of identical twins with bipolar disorder, but epigenetics, he explains, may account for the 30 to 70 percent of cases where only one twin has the illness.

Identical twins share the same DNA, but their epigenetic material may be different. Moreover, whereas DNA variations are permanent, epigenetic changes are in a process of flux and generally accumulate over time. This may explain, Dr Petronis theorizes, why bipolar disorder tends to manifest at ages 20–30 and 45-50, which coincides with major hormonal changes, which may "substantially affect regulation of genes ... via their epigenetic modifications."

The dynamics of epigenetic changes may also account for the fluctuating course of bipolar, Dr Petronis speculates, perhaps more so than static DNA variations.

Finally, as Scientific American points out, the fact that epigenetic anomalies can be reversed makes them inviting targets for a new generation of meds.

In a 2003 pilot study, Dr Petronis and his colleagues investigated the epigenetic gene modification in a section of the dopamine 2 receptor genes in two pairs of identical twins, one pair with both partners having schizophrenia and the other having only one partner with the illness. What they discovered was that the partner with schizophrenia from the mixed pair had more in common, epigenetically, with the other set of twins than his own unaffected twin.

Check out this 2010 Time Magazine piece on epigenetics.

Robert Whitaker: Dangerous in America - Part II

Yesterday, I reported on Robert Whitaker’s dangerous tendency to play fast and loose with the facts in support of his own agenda. This worked in his 2010 book, “Anatomy of an Epidemic,” which I was largely supportive of despite my strong reservations over the way he misrepresented the studies he relied upon to make his point, not to mention his unpardonable cheap shots fueled by his profound ignorance in areas he proved too lazy to research.

Nevertheless, the strands of his argument held together, and his concerns matched our concerns. Essentially, Whitaker had made a strong “case to answer” that our meds may bring on the very conditions they are supposed to prevent. Nearly two years following the publication of his book, in the absence of psychiatry failing to answer his case, I concluded two months ago that “Whitaker stands as the most authoritative voice on psychiatric treatment.”

I strongly urge everyone to read Whitaker’s book, discuss it with your friends, do your own research, and reach your own conclusions. The life you save may be your own.

In his last two posts on his blog Mad in America, however, Whitaker appears to have lost touch with both the facts and the people he purports to serve. As I reported yesterday, in a piece posted on Jan 12 Whitaker egregiously misreported the facts of an NIMH-funded study in support of his own idiosyncratic white whale hunt.

But who has time to fact-check Whitaker? Especially those willing to take him at his word.

Nevertheless, one of his own readers smelled a rat. In a comment to his post, Don B noted “his approach to the whole problem of mental illness comes off as the outsider who knows it all about what he has never personally experienced.”

Don’s post is long and involved, but the gist of it involves his resentment over Whitaker thinking that “he knows what is best for me. If he is politically correct, he wouldn’t dare tell a woman that he knows how it feels to get raped or to have a miscarriage. But like many others, he does not shrink from telling those of us with mental illness what choices to make.”

As if to prove Don’s point, in his next blog post Whitaker makes the bizarre and totally irresponsible claim that the NIMH is advancing some kind of eugenics agenda. I'm not making this up. It's actually in the title of his post, that reads in full: "The Taint of Eugenics in NIMH-Funded Research Today." Apparently, NIMH research is warped from the outset, and Whitaker's proof for this is a repetition of his nonsense from his previous post about no miracle cures in the last 30 years.

In Whitaker’s own words:

[NIMH head] Insel’s list tells of a research enterprise devoted to identifying what is genetically wrong with the “mentally ill.” As the history of eugenics reminds us, that is a pursuit, unless it is handled with great care, that can engender bad social policy and a great deal of harm.

Right, Whitaker, and President Obama is a Muslim born in Kenya ramming European socialism down our throats.

Okay, Whitaker, reality check: There is something wrong with us. Profoundly so. Otherwise, I would be employable. Otherwise, a dear friend of mine would not have thrown himself in front of a train. Otherwise a friend from my past would not have shot himself with a gun. Otherwise, someone I know would not be sitting in a prison cell as I write this. Otherwise, otherwise, otherwise ...

Do you think mental illness is a fucking picnic, Whitaker? I know you have done a lot of talking, but have you actually done any listening? Do you actually know what it’s like when you can’t get out of bed in the morning? When the mysterious force inside your head that is keeping you there is every bit as strong as all the gravity Newton could ever contemplate?

Shut up, Whitaker. I’m not finished: Do you know what it’s like when your brain goes on strike? To be clinically dead but breathing? Or to experience a psychic pain so intense that, yes, the one way out - the unthinkable - is the totally logical choice?

Or maybe it’s the other way around. Your brain runs away from you. Suddenly, you’re thinking and feeling and doing all kinds of crazy shit. Try living inside of my head for one second of that, Whitaker. I dare you to write your stupid shit after that.

Wait, there’s more. The finger-pointing, the ostracism, the social isolation. That’s right, Whitaker, when something goes wrong - yes wrong - the people around us do not exactly respond with the same forbearance as Father Damien in a colony of lepers. And there we are, our lives in ruins, left to pick up the pieces.

And - oh, yeh - our families, our loved ones, our friends and colleagues. For one second, Whitaker, can you even begin to imagine what mental illness does to these innocent bystanders?

One day, Whitaker, we should sit down and have a beer together. Then I can tell you all this to your face.

Robert Whitaker: Dangerous in America

On his Mad in America blog, in a Jan 12 post Rethinking Brain Research in Psychiatry, Robert Whitaker, author of "Anatomy of an Epidemic," made the very legitimate point that brain studies on those with mental illness fail to account for the effects of exposure to psychiatric drugs.

Agreed. So, if you slice and dice the brains of deceased individuals with schizophrenia and bipolar and compare them to “healthy” brains, as scientists at the Scripps Institute very recently did, and find that DNA “stays too tightly wound” in the brain cells of schizophrenia subjects, is the effect attributable to the illness, as the researchers suggested, or to the meds the patients have been on all these years, as Whitaker argues needs to be controlled for?

Furthermore: If we can’t say for sure, is the study actually worth the paper it’s printed on? No to everything, says Whitaker most emphatically. “First, let’s look at this particular study,” says Whitaker, who then does not look at this particular study. What Whitaker fails to mention is the study’s real finding and its implications: that a certain gene regulation process observed in neurological disorders also has a correlation to schizophrenia.

The study, published in Translational Psychiatry, sheds very important light on the developing field of epigenetics, which is rewriting the entire book on genetics. If you haven’t heard of epigenetics, don’t worry - you will. I first reported on the topic back in 2004, when a PubMed search listed but one author researching bipolar from an epigenetic perspective. Now epigenetics is emerging as the main event. Last year, I heard Jonathan Sebat of UCSD talk about “copy number variants” in schizophrenia and autism.

Back to the study: The devastating effects of the acetylation of histones (which appears to drive the “tightly wound” DNA dynamic) is the narrow story. The insights the study sheds into the dynamics of epigenetics is the wider story. Both together add up to the real story. Here is the scientific gobbledygook from the research article:

The major findings from this study are: (1) histone ac-H3K9K14 levels are correlated with gene expression levels for several schizophrenia-related genes, including GAD1; (2) age is strongly negatively associated with promoter-associated histone acetylation levels in normal subjects and those with bipolar disorder, but not schizophrenia and (3) histone H3K9K14 levels are hypoacetylated at the promoter regions of important genes in young subjects with schizophrenia.

Maybe another group of scientists will discover that psychiatric meds are involved in the histone acetylation process, but a further study would require funding, and here Whitaker has his own agenda.

Whitaker says the researchers at Scripps could have “administered neuroleptics to healthy rats.” Huh? This was an epigenetics study, not a drug company pre-clinical trial. Does Whitaker even know the difference? Has Whitaker even heard of epigenetics?

“This is why I think it is time for the NIMH to reallocate its research dollars,” says Whitaker. “Decades of such brain research has not produced any notable therapeutic payoff.”

And it is an absolute certainty that there will be no payoff if propagandists such as Whitaker have their way. For there to be any kind of therapeutic pay-off, first we need to find out what is really going on in the brain. NIMH research has led the way in busting old myths (ironically, Whitaker relies on this research in Anatomy of an Epidemic) and has totally changed how we think about brain function and mental illness.

But it also reveals how little we truly know. Alas, there are no easy answers. All the low-hanging therapeutic fruit has already been plucked. Research is badly underfunded, especially with no short-term pay-offs in sight. Today's research efforts are for the benefit of future generations. That's what civilization is all about. We work, we sacrifice, for those who come after us. But there are no guarantees in the frustrating and noble quest for knowledge.

Rerun: Mahler: The Man Who Saw It Coming

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bernstein conducting the opening to Mahler's Fifth

The Book of Fort: The Two Wise Old Fools

Book II in the series ...

At the watering hole, along the barrens of Fey, on the fork of the road leading to Mem in one direction and Ar in the other, the wise and righteous Fort encountered a weary stranger in threadbare garments. And although Fort would later go hungry, he offered the stranger his last loaf, which the man eagerly consumed.

Fort bid the stranger to make himself comfortable, then asked his name.

“They used to call me Saul,” the stranger replied in a defeated voice.

“And what do they call you now?” inquired Fort. “It hardly matters,” the man replied. “Just call me Saul.”

Whereupon Saul related an account when, as a much younger man, God had appeared to him in a vision, and thus filled with this vision he had traveled far and wide, enduring many privations, braving persecution and hardship, to spread the good news.

"Five times, in the hands of my own people,” he related, “I have received the 40 lashes minus one. Thrice was I beaten with rods. Once was I stoned, thrice I suffered shipwreck, a night and a day I have been in the deep. Angry mobs, robbers, betrayal from my brothers, in toil and hardship, through many a sleepless night.”

“Indeed, you have endured much,” said Fort, “and your undertaking has been very noble.”

But Saul only shook his head in resignation. “I was young, I was foolish,” he reflected. “I thought I could change the world.”

“And now?” Fort inquired.

“I am old and wise,” Saul replied. “No one listens.”

“Indeed, you are very wise,” Fort replied.

“Wise enough to know the follies of my ways,” said Saul.

“But surely,” protested Fort. “There is great merit in service to God.”

“And how does God repay me?” Saul replied. “By sinking my boat.”

“Indeed,” allowed Fort, “God is hardly worthy of your service. But your people, your followers, surely they possess far greater wisdom. Surely, their numbers are legion.”

Saul laughed bitterly. Casting one arm over the empty expanse of the barrens, he observed, “Ah, the multitudes. As you can see, I never get a moment to myself.”

“But you are far from home,” protested Fort. “Surely, upon your return, by a warm hearth, you will be welcomed with open arms.”

Saul made a sad face.

“I understand,” said Fort. “Had only your own people proved worthy, it would have been easy to forgive God. But perhaps neither God nor your own people are to blame. Perhaps it is your message that is unworthy.”

Saul’s aspect appeared questioning.

“A worthy message,” explained Fort, “would have attracted people of high status and considerable means. You would be supping with kings. You would be resting your head upon fine cushions. Heralds would be proclaiming your wisdom far and wide. Alas, if only your message were worthy.”

“Alas,” acknowledged Saul, “my message fell on deaf ears. Only people of no account listened.”

“People of no account,” repeated Fort.

“People of modest means,” explained Saul, “barely able to eke out a living. Not to mention people of no means and wretched status, outcasts, slaves, women, lots of women.”

“The wrong people,” Fort concurred. “People of no use to you. Clearly, what have they done for you?”

A flash of anger appeared in Saul’s eyes. “They took me in,” he exclaimed in a voice robust with indignation. “They provided for me with what little they had. They journeyed with me. They shared my hardships with me. They risked their lives for me.”

Fort affected to reflect upon the matter. “Ah,” he said at last.

“Gladly,” said Saul, “for these people, I would have God sink my boat - again and again.”

“Ah,” said Fort.

And the realization dawned in Saul’s eyes. Tears flowed down his cheeks, his carriage trembled. “I am greatly indebted to you,” said Saul to Fort. “You are indeed a very wise man.”

“A wise old fool,” Fort corrected in a kindly voice, “far from home, like you.” He rose to his feet, and indicating a road branching off from the fork, he said to Saul, “You are a very worthy man. I would be most honored if you joined me.”

But Saul pointed in the direction of the other road. “My path lies this way,” he said.

“A very lonely road,” observed Fort.

“A very lonely road,” concurred Saul.

“Yet more privation and hardship lies ahead,” Fort cautioned. “You are old, your condition is weak.”

“My strength is made perfect in weakness,” Saul replied, as Fort helped him to his feet.

“Spoken like a wise old fool,” said Fort, with approval in his manner.

A robust laugh issued from Saul. “A wise old fool,” he agreed.

“I would bid you God speed,” said Fort, with a twinkle in his eye, “but you and God have not exactly reached a meeting of the minds in this regard.”

“And I would wish you God bless,” Saul responded, his manner mirthful, “but you and God have probably come to your own arrangement.”

They embraced. “God speed,” said Fort. “God bless,” said Saul. They broke off their embrace, then parted company and headed their separate ways, two wise old fools.

***

And so it came to pass, far along the road, that Fort related his encounter to a band of pilgrims from the land of Rho, making their way to The Place. And the travelers marveled over this wondrous account of the strange man who had apparently wasted his life serving such a God of infinite unyielding disdain.

“It is not easy being God’s servant,” Fort allowed.

And what do you think became of this strange man? they inquired.

“That I cannot tell you,” Fort replied. “But I can venture this - that this time around, on the last leg of his journey, my guess is that God did not sink his boat.”

Also see Book I.

Newt the Borderpath: Making the Case that Psychiatry is Not Allowed to Make

Picking up where we left off ...

Thanks to “the Goldwater Rule” embedded into the code of ethics of the American Psychiatric Association, it is unethical for psychiatrists to “offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

The rule was the direct outcome of more than a thousand psychiatrists venturing negative (totally un)professional opinions about 1964 Republican Presidential candidate Barry Goldwater in response to a Fact magazine survey.

The rule effectively precludes psychiatrists from publicly stating the obvious, namely that current Republican Presidential front-runner Newt Gingrinch is “a walking-talking DSM-IV Axis II, Cluster B special, displaying a suite of bizarre behaviors distributed along at least three diagnoses, including borderline personality disorder, narcissism, and antisocial personality disorder.”

Of all the crazy things, the framers of the Goldwater Rule almost certainly never envisioned the bizarre possibility of one of its own reaching exactly the opposite conclusion, namely how Newt’s abundant character flaws might actually make him a better President. This happened last week when psychiatrist Keith Ablow scribbled an over-the-top commentary to that effect on Fox News. The gist of his thesis was that the cold-blooded indifference Newt displayed in dumping his first two wives is precisely the quality required of our next President in being “direct and unsparing with the Congress, the American people and our allies.”

Ironically, any psychiatrist jumping in to refute Ablow’s nonsense can only do so at the risk of incurring disciplinary action by the APA. Okay, we know the dangers of judging people we have never met, but what about public figures we may know better than members of our own family? Clearly, the public interest demands critical evaluation from the psychiatric profession.

With Newt Gingrich, it turns out, the exercise is as easy as shooting fish in a barrel. To focus on just one incident:

In 1995, Newt Gingrich as House Speaker initiated a 22-day federal government shutdown. In the midst of the crisis, Gingrich attributed his hardline stance to a perceived “snub” from President Clinton, who purportedly did not talk to him during a flight on Air Force One to Israel for the funeral of assassinated Prime Minister Yitzhak Rabin.

I’m not sure which is worse: A man putting millions of Americans in jeopardy as a result over his own damaged ego, in total disregard for their concerns, or expecting his victims (the American public) to identify with his pain. It turns out that Clinton had photos of the two talking on the trip.

In an op-ed piece in the Feb 25, 2011 Washington Post, Gingrich recast his outrageous conduct as a stand on principle, blaming President Clinton for vetoing a Republican budget and the “liberal media” for misreporting the issue, claiming that the short-term pain of the shutdown set the stage for later budget deals.

“So, we faced a choice,” he wrote. “We could cave in and be accepted by the Washington establishment, or we could stand firm for a balanced budget for the American people.”

There really is no issue here: The only thing that psychiatrists should be arguing about is which diagnostic category to stick Newt in. Three of the Cluster B personality disorders come immediately to mind - narcissism, borderline, and antisocial - with some element of paranoia thrown in. But as psychiatrists and psychologists are quick to point out, personal pathology is far more fluid and subtle, not amenable to diagnostic boxes.

So let’s dispense with choosing between this diagnosis or that diagnosis and going with a bit of each. This is the approach Barbara Oakley took in her 2007 book “Evil Genes: Why Rome Fell, Hitler Rose, Enron Failed and My Sister Stole My Mother's Boyfriend,” which has received considerable play on this blog.

As you recall, Dr Oakley characterized certain individuals as “successfully sinister,” your classic Machiavellians - charismatic and ruthless - out for themselves at the expense of anyone unfortunate enough to happen to breathe the same air. Her Machiavellian poster boy is Chairman Mao, whom she describes as “the perfect borderpath,” exhibiting  clear elements of borderline and psycho/sociopathy (plus generous helpings of narcissism and paranoia).

In the chaos of China, to the considerable detriment of a quarter of the world’s population, Mao was able to exploit his pathology to attain a position of absolute power for more than three decades. In a democracy, a borderpath is inclined to reach a more modest pinnacle. To quote from one of my earlier pieces:

In politics, says Dr Oakley, an American-born Mao might have become a populist demagogue in the 1930s Huey Long mold (I will leave the obvious contemporary examples to others) ...

Do you detect an obvious contemporary example? With the stakes much higher? Pity that psychiatry can’t talk about it.

Challenging the Bipolar-Sex Conventional Wisdom

I just added a new article to mcmanweb, The Whole Bipolar Sex Thing, which had its genesis in a series of posts on HealthCentral. Following is an extract ...

The conventional wisdom is that (hypo)mania increases our sexual drive - often to the point of excess - while depression has the opposite effect. Goodwin and Jamison in their 2007 "Manic-Depressive Illness" note that Aretaeus of Cappadocia in the second century AD observed "a period of lewdness and shamelessness exists in the highest type of [manic] delirium."

The authors cite a number of studies showing increased sexual interest and behavior during mania or hypomania, and the DSM makes it official by including "sexual indiscretions" in manic and hypomanic episodes. It also notes "decrease in sexual interests or drive" during depression.

Okay, time to challenge that notion. A 2006 NIH-funded study of a large teen population found that those who were depressed were far more likely to engage in risky behaviors such as drug use and sex. The study corroborates earlier findings.

One aspect of depression is a feeling of being "clinically dead but breathing," the very opposite of the "feeling alive" states of mind we experience in pure mania and hypomania. But something else also tends to be going on - intense psychic pain. If the clinically dead aspect of depression is about feeling too little, our psychic pain is about feeling too much. In this tortured state of mind we tend to be desperate for release, and seek it in a variety of ways - from attempting suicide to over-eating and over-sleeping to alcohol and drug abuse to "retail therapy" to the flood of feel-good hormones from a warm embrace.

The feeling may quickly wear off, but so what? People who have never experienced depression cannot possibly understand.

Thus both sides of the bipolar equation find us at risk, up as well as down. Yes, it is true that we are more likely to lose interest in sex when we are depressed, but this should not mask the fact that in certain instances the very opposite may occur, replete with the full menu of life-altering consequences. Psychic pain has that kind of effect on us.

Do Bipolars Make the Best Lovers?

Does hypersexuality in mania and hypomania actually translate to being better in bed? We have no evidence.

What is reasonable to assume is that our ups intensify all our experiences, whether listening to music, enjoying food, watching a sunset, or having sex. Even our downs can add layers of richness to our existence.

But is it possible for those close to us to experience our subjective realities? The answer appears appears to be yes. Our states of mind can be contagious. Wrote Kay Jamison of Virginia Woof, citing one of her social circle: "I always felt on leaving her that I had drunk two excellent glasses of champagne. She was a life-enhancer."

But the very intensity of our world can also be very frightening to others. Virginia Woolf may have lit up her Bloomsbury circle, but she also drove poor husband Leonard nuts. Likewise, the intensity factor has a way of drowning out the rest of our surroundings, including the people around us.

So - let's make a few wild guesses about what happens when we take our enhanced subjective realities to the bedroom. When things go right, it appears that the intensity we bring to the moment jumpstarts the "normal" partner's intensity, and next thing both partners are experiencing the type of cosmic union you read about in the poetry of Rumi.

Sample verse: "You are the sky my spirit circles in."

But maybe things get too intense for the comfort of our partner, perhaps to the point where he or she no longer feels safe. Maybe we are so into our own needs and desires that we lose sensitivity to those of our partner. We fail to pick up vital signals. We fail to make the necessary adjustments. Sex is mind-blowing enough without adding bipolar to it. Thus, if we are prepared to brag about how bipolars make the best lovers, we also need to accept the fact that there are times when we are probably the worst.

The "Bipolar-By-Proxy" Complication

Jumpstarting our partners may have the effect of turning them into "bipolar-by-proxy." This is wildly speculative, but let's run with it. If our partner is feeling the same kind of intensity we are feeling, with similar dopamine surges, then their capacity to make rational decisions may be as impaired as ours, perhaps more so. We at least have an experiential context to place our current state of intensity. Our partner may confuse this novel experience with love.

For the full article, check out The Whole Bipolar Sex Thing

Newt and "The Goldwater Rule": Why Psychiatrists Will Not Tell You the Obvious

“Newt Gingrich’s three marriages mean he might make a strong president - really,” ran the headline to a Fox News article published last Friday. What else would you expect from the publicity arm of the Republican Party? The twist was the article was written by a psychiatrist, not just any psychiatrist, a psychiatrist employed by Fox News, Fox News’ house psychiatrist Keith Ablow. Dr Ablow also co-authored a book with Glenn Beck and makes a decent living as a celebrity psychiatrist who has appeared on Oprah and other shows.

In his Friday article, Dr Ablow made the extraordinary claim that Newt Gingrich’s marital infidelities might actually make him a better President. The article was a response to allegations from his second wife that surfaced the day before. On Saturday, Gingrich handily won the South Carolina Republican Primary. Wrote Ablow:

When three women want to sign on for life with a man who is now running for president, I worry more about whether we’ll be clamoring for a third Gingrich term, not whether we’ll want to let him go after one.

Ablow also cited Newt’s cold-blooded indifference to his first two wives as a virtue. Really, I am not making this up. In Ablow’s words:

Two women - Mr. Gingrich’s first two wives - have sat down with him while he delivered to them incredibly painful truths: that he no longer loved them as he did before, that he had fallen in love with other women and that he needed to follow his heart, despite the great price he would pay financially and the risk he would be taking with his reputation.

Conclusion: I can only hope Mr. Gingrich will be as direct and unsparing with the Congress, the American people and our allies. If this nation must now move with conviction in the direction of its heart, Newt Gingrich is obviously no stranger to that journey.

Ablow’s article raises a host of issues, the most obvious being why a man speaking as a psychiatrist would be penning such nonsense. Shouldn’t it be the other way around? Shouldn’t we be hearing from a panel of mental health professionals on why Newt is psychologically unfit to hold high office?

The reason you are only hearing journalists and lay commentators ruminating on Newt’s (and other candidates’) putative craziness has to do with psychiatry’s “Goldwater Rule.” Some background:

In 1964, a month before the Presidential election, Fact magazine went to press with this headline: “1,189 Psychiatrists Say Goldwater is Psychologically Unfit to be President!”

The Republican candidate Senator Barry Goldwater of Arizona was a conservative ahead of his time. By 1980, when Reagan swept into office, his ideas were mainstream. By today’s standards, Goldwater would be considered a moderate and on some issues a liberal. By any standard, he was a man of high moral character. Ironically, it was his rival LBJ who would unravel in the Oval Office (see my two posts: Was LBJ Bipolar? The Case For, The Case Against).

Fact magazine sent questionnaires to 12,356 psychiatrists listed by the American Medical Association. Of the 2,417 who replied, 1,189 called him unfit. The eagerness of such a large percentage of its membership to issue summary personal judgments disguised as professional opinions alarmed the powers-that-be to the point that six years later, the American Psychiatric Association issued section 7.3 of its code of ethics that reads in part:

... it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

The section is only binding on psychiatrists, but clearly psychologists feel constrained by it. The “Goldwater Rule” is why you don’t hear psychiatrists or psychologists stating the obvious: That Newt is a walking-talking DSM-IV Axis II, Cluster B special, displaying a suite of bizarre behaviors distributed along at least three diagnoses, including borderline personality disorder, narcissism, and antisocial personality disorder.

Mind you, as Nassir Ghaemi made abundantly clear in his 2011 book “A First-Rate Madness,” we don’t want our public figures overly normal, either. In certain situations, a bit crazy can be good.

Clearly, the public would be served by hearing an educated discussion on the matter, but the APA does not trust its members enough to restrain themselves. This brings us back to the Ablow’s off-the-wall Fox News piece. Did he breach the Goldwater Rule?

The framers of section 7.3 almost certainly did not foresee the possibility of one of its own employing twisted logic to turn appalling behavior into a character virtue. Had it been the other way around - had another psychiatrist sounding off on MSNBC reached the more obvious conclusion - we would probably hear Fox News screaming for that individual’s head.

That’s how crazy things are.

Much more to come ...

The Book of Fort

The other day, while hiking in the mountains, I came across some ancient writings secreted in a cave. Clearly, they are Scripture from a forgotten people. I just finished translating the first scroll ...

And there lived in the land of Gob a righteous man named Fort, who was a crafter of fine hardwood didgeridoos. And his didgeridoos were strong and resonant and affordable and brought great joy to the people of Gob. And so it was that Fort prospered. And as he aged, he would preface his comments with, “When I was young and foolish ...” And thus the people of Gob came to regard Fort as old and wise, and indeed he was.

One day a seeker of wisdom appeared in his didgeridoo shop and asked: “Wise Fort, show me God.” And Fort replied, “Alas, son, I cannot do that, for I do not presume to know God." And the seeker asked: “Wise Fort, explain to me the meaning of life.” And Fort replied, “Alas, son, I cannot do that, for I do not presume to understand the mysteries of life.”

And the seeker asked: “Wise Fort, show me how to make a didgeridoo.”

And Fort replied: “Come closer, my son. That I can show you.”

***

And so it passed that an ox gored a young man to death, which would have been of no account but for the fact that the ox and young man had two different owners. And the owner of the young man sought restitution from the owner of the ox. But the owner of the ox refused, claiming that an ox of high status had every right to gore to death a young man of no status.

And this would have been accepted as entirely reasonable had the man of no status been owned by a man of low status. Alas, the man of no status was owned by a man of high status. And so a great dispute arose in the land of Gob, and neighbor began regarding neighbor in the type of reproachful manner that recalled the Dark Times that ended the Golden Age that preceded the Day of Reconciliation that gave rise to the Era For Which There is No Name.

Surely, they said, God must have anticipated an event of this nature would occur. And if that is so, they reasoned, then God must have anticipated all manner of events, and so must have come up with laws to govern the entire realm of human endeavor. And if that were so, then God would have provided clear rules to resolve all disputes.

Therefore, the people of Gob reasoned, God must have issued a Code. And so it was that the people of Gob called upon Fort, crafter of fine didgeridoos, to go to the top of the mountain for forty days and forty nights - or 40 nights and 40 days, whichever came first - seek out God, and return with the Code.

Forty nights and forty-one days later - or forty days, accounting for time off - Fort returned from the mountain with a large rock shaped like a tablet.

Did you return with God’s Code? asked the people of the Land of Gob.

I did not, replied Fort. But I did come across this rock with some writing on it.

Surely, they said, that must be the word of God.

Judge for yourself, said Fort.

What does the Code say? the people of Gob enquired.

And spoke Fort, It says thus:

“The stupidest idea - indeed must odious, most pernicious - ever devised by Man is that certain men regard themselves as superior to others and others as inferior to themselves.”

That is all that God says? asked the people of Gob.

That is all the rock says, replied Fort.

And the people of Gob pondered the matter for days into weeks and concluded that the rock conveyed wisdom that was far beyond the realm of mere mortals and so must be the Word of God. And having been singled out by God, they concluded that they must indeed be special. And they resolved to live by God’s Code.

And by living by God’s Code, they immediately regarded themselves as superior to others and others as inferior to themselves.

***

And so it came to pass that the most superior of the superior people in the land of Gob reasoned thus: If God possessed the wisdom to issue a Code of such profound infinitude - or infinite profunditude, as the case may be - His thinking has to be nuanced beyond imagination.

And indeed, if this is so, then God must have issued a longer Code, a Code in two parts, the second part which would have contained exceptions to the first part. And so they dispatched a delegation of Elders to the top of the mountain to find the second tablet which would have contained the second part of the Code.

Alas, the Elders failed to return with the second tablet, but by now, thanks to the wisdom conferred by the first tablet, they now possessed the insight to deduce the wisdom of the missing second tablet, and so came up with a long and detailed list of exceptions to the first.

And this list of exceptions was loudly acclaimed by the people of the land of Gob, especially among the superior of superiors. And thus the Era For Which There Is No Name gave rise to the Era of Great Prosperity, at least according to some.

More to come ...