Friday, October 30, 2009

Halloween Special - The Friday Frights

My good friend Therese Borchard of Beyond Blue looks positively frightening in this Halloween special video, Facing Your Fears, released today. But for sheer fright quotient, you need to see me doing rap. My video, Gonna Build Me a Tree, was shot last year. As to who is more frightening, me or Therese, you be the judge - but remember, I didn't need to wear special makeup. Enjoy ...

Thursday, October 29, 2009

Great Moments in Sports History - Game 7 of the 1960 World Series

Any enemy of the Yankees is a friend of mine. Nothing personal, just normal blood feud stuff, you know, like the Montagues and Capulets, Bloods and Crips, Mac and PC. Last night, the Yankees and Phillies opened the World Series, which makes me a die-hard Phillies fan for the next week.

I grew up in a Red Sox household in the middle of Connecticut, almost midway between New York and Boston. This meant that every day of my life, I endured the incessant put-downs of those fortunate enough to have been born of Yankee parentage. This was the era of Mickey Mantle and Yogi Berra and Whitey Ford. I think after Ted Williams retired, Eva Gabor was the power hitter for the Red Sox.

The Yankees were perennial pennant winners all during when I grew up. This meant every fall I cheered for whoever they went up against in the World Series - the Milwaukee Braves in '57 and '58. The LA Dodgers (alas, no longer in Brooklyn) in '59 - wait, the Yankees weren't in the World Series that year ...

What you are looking at is the equivalent of my Mount Rushmore, Statue of Liberty, Washington Monument, and tribute to the guy who invented peanut butter combined. On the site of the old Forbes Field in Pittsburgh marks the spot where Bill Mazeroski's winning home run landed in the ninth inning of the seventh and deciding game of the 1960 World Series between the Pirates and Yankees.

Without doubt, until the Red Sox actually won a World Series in 2004, this was the greatest moment in all sports history in the entire existence of the universe, including galaxies far away. (Have I made my point?)

This was the Yankees tenth World Series in twelve years, the Pirates first since getting pummeled by Babe Ruth and the Yankees' infamous Murderers Row in 1927. Again, the underdog Pirates were hopelessly outgunned. After squeaking out an opening victory of 6 to 4, the Yankees unequivocally reminded the Pirates who was boss in the next two games with scores of 16 to 3 and 10 to nothing. Then the Pirates squeaked two in a row - 3 to 2 and 5 to 2 - only to be bombarded by the Yankees in the sixth game by a score of 12 to nothing.

If this were five-day cricket, the Yankees would be leading 46 to 17. Instead, the Series was improbably tied at three each. It all came down to the final game. This time, at home, the Pirates mustered the necessary firepower. Trailing 7 to 4 after seven innings, they banged out five runs in the eighth to take the lead. But the Yankees tied the score in their turn at bat in the ninth with two more runs.

I will never forget the moment. Back in those days, they played games in the afternoon, which meant kids could actually watch. I got off the school bus at my friend Kenny's house and together, as her mom looked on, we sat on the edge of our seats as the last part of the game unfolded. It was the bottom of the ninth. First batter up was second baseman Bill Mazeroski. Definitely not a power hitter. One ball, no strikes. We held our breaths. The wind up and the pitch ...

Smack! The camera swung toward the ivy brick wall in left field. The announcer went crazy. It could only mean ...

Home run! Home run! Home run! The Pirates win the Series!

Forbes Field instantly erupted into what was then the loudest spontaneous human-generated sound in recorded history. Mazeroski headed into second, whipped off his cap and swung it round and round in celebration. As his teammates mobbed him at the plate, the Yankees on the field simply stood in their positions in postures of shock and disbelief.

These were the days before instant replay. I didn't need one. My neurons lovingly recorded every frame. My mind is playing back the great moment right now. What a scene. What a memory ...

Wednesday, October 28, 2009

Listening to Mental Illness

Talk - I should say, listen - to first-generation NAMI family members. These are people in their 70s or 80s caring for sons and daughters in their 40s and 50s and 60s, individuals with severe mental illness such as schizophrenia. Back in the bad old days, both the mental health profession and society-at-large turned their backs on these fathers and mothers. They were blamed for being bad parents.

Things haven't improved all that much over the years. Keep listening and you will hear their concerns about who will look after their kids after they are gone.

We know the world is a cruel and indifferent place, but nevertheless you can't help but want to shake your fist at the heavens like some lonesome prophet on a wilderness mountain top.

You will hear similar stories from a younger generation of parents, this time mothers and fathers of young kids with bipolar. Again, the lack of empathy and concern from people who should know better. Again, people blaming them for being bad parents.

Two previous blog posts - Age Six and Age Seven With Schizophrenia - sympathetically featured Jani Schofield, a seven-year-old who has been diagnosed with schizophrenia. Surely, that cannot possibly be true, is a justifiable first and second and even tenth reaction. Earlier this year, her father Michael began an eye-opening blog, January First, documenting Jani's extraordinary situation and the extreme distress it is causing her family.

Shari Roan of the LA Times picked up on the blog, and just recently Oprah devoted a whole show to Jani. Both the LA Times and Oprah were highly sympathetic, both to Jani and her family. Mental health journalist Robert David Jaffee, writing yesterday on the Huffington Post, also evidenced clear empathy. As Mr Jaffee reports:

The expression, "I had a bad childhood," has never seemed sufficient for describing the horrors visited upon many youth. The expression's inadequacy becomes apparent when one hears the story of Jani Schofield, a seven-year-old, who has been diagnosed with schizophrenia and has already been hospitalized seven or eight times in psychiatric wards. Typically, psychotic disorders afflict people no earlier than their late teens.

Though we live in an era where too many have been over-diagnosed and over-medicated, the case of Jani Schofield makes one realize that not all diagnoses are created equal and some diagnoses, like child-onset schizophrenia, will never be fashionable.

It is important to note that Shari Roan, the producers of Oprah, and Oprah herself, all had conversations with Jani and her parents, while Mr Jaffee interviewed Jani's mother Susan. A far different response came from those who simply interviewed their keyboards. Blogger Liz Spikol, citing Furious Seasons with approval, was all too representative:

Michael Schofield’s voice on his blog makes him come across as a very angry person with serious anger management issues–a person who’s self-aggrandizing and resistant to learning new things.

A few days ago "An Open Letter to Oprah Winfrey," signed by 95 mental health workers, patients, and family members from an organization called Intervoice, added a new twist. According to Intervoice:

We want to tell you about an alternative and more empowering approach to the experience of hearing voices. ...

The letter continues:

It is important that we appreciate that the desire to make the voices disappear is a goal of the mental health care services and not necessarily that of the children themselves. There are some children who did not want to lose their voices. This is OK, for the most significant thing is that the voices no longer remain at the center of their attention. This is because, as the relationship with the voices change and became more positive, instead of hindering the child the voices start to take on an advisory role. If children find within themselves the resources to cope with their voices, and the emotions involved with hearing them, then they can begin to lead happier and more balanced lives.

The most important element in the process of positively changing a child's relationship with his or her voice is support from the family. Unfortunately, our research has shown that being in the mental health care system had no positive effect on the voices. However, we did find that what had a positive influence on how the child coped with hearing voices was being referred to a psychotherapist who accepted the reality of the voices and was prepared to discuss their meaning with the child.

Had not Jani been brought into the conversation, there would be a lot of merit in this point of view. This is an extremely important topic that deserves a full airing, but not in the context of Jani. Any reader of Michael's January First blog realizes that there is far more going on with Jani than simply hearing voices. Her unpredictably violent and explosive outbursts have compelled her besieged parents into leasing two separate apartments, so that one parent (and Jani's younger brother) can get a break.

Ironically, Jani and her family seem to have been applying the Intervoice prescription all along. From the online video clips of the Oprah episode, it is apparent that Jani is already comfortable with her hundreds of voices, denizens of her imaginary "Calalini" world. Moreover, it is clear her parents support her in this.

But now, it seems, Michael and Susan are losing their daughter to her fantasy world. As Michael reports on his blog:

The point is that the real world is increasingly becoming irrelevant to Jani, something that was not the case at two years old. Jani was acutely aware and sensitive to others around her up to the age of three. In fact, her needs seem to come second to the world around her. Starting at three, she went backwards to the point that now she is more like a toddler than she when she actually was a toddler in the sense that Jani’s interaction with the world is often limited to her basic needs (food, bathroom, sleep).

I realize I am stating all of this in a coldly intellectual way. It is a defense mechanism. Right now I have detached myself emotionally and am looking at this as if I was an outside observer because in reality I am losing this War. I am losing my daughter. ...

Tuesday, October 27, 2009

Father of the Lobotomy

I wrote this piece on my mcmanweb site eight or nine years ago, with a minor addition a few years back. This highly macabre piece remains one of the most popular on my site, and in the spirit of Halloween I'm re-running it here. Enjoy ...

The field of mental health suffers no shortage of weird and offbeat and arguably despicable characters, but the Washington Post several years ago outdid itself for its story on Walter Freeman, father of the lobotomy. Sample this lurid paragraph for starters:

"Walter Freeman lifted the patient's eyelid and inserted an ice pick-like instrument called a leucotome through a tear duct. A few taps with a surgical hammer breached the bone. Freeman took a position behind the patient's head, pushed the leucotome about an inch and a half into the frontal lobe of the patient's brain, and moved the sharp tip back and forth. Then he repeated the process with the other eye socket."

Freeman kept records of 3,439 lobotomies he performed over his long career, and he promoted the procedure to more than 55 hospitals in 23 states. At AMA meetings, he set up graphic exhibits and used hand-held clackers to draw audiences.

In all, lobotomies were used on 40,000 to 50,000 Americans between 1936 and the late 1950s. Freeman believed lobotomies worked because the procedure severed connections between the frontal lobes of the brain and the thalamus, thought to be the seat of human emotion, which the mentally ill apparently had in overabundance. Although his theories have been discredited, Freeman was one of the few psychiatrists of his era who believed that mental illness had a physical biological component.

Freeman attended Yale and the University of Pennsylvania School of Medicine, then studied neurology and psychiatry in Europe. Motivated by the tragedy of wasted lives in mental hospitals, he introduced insulin shock therapy and ECT for patients at George Washington University Hospital in Washington DC, where he served on the faculty. He also had a private practice and was director of the laboratories at St Elizabeth's Hospital.

Upon finding out that chimpanzees became subdued when their frontal lobes were damaged, and spurred into action by Portuguese neurologist Egas Moniz' experiments on people, he and colleague James Watts started practicing on brains from the hospital morgue, and in 1936 they were ready for their first patient, a Mrs Hammatt, 63, who suffered from agitated depression and sleeplessness. The technique of entering the frontal lobes through the eye sockets was still far off into the future. Instead, they drilled six holes into the top of her skull.

According to Freeman, Mrs Hammet emerged transformed, able to "go to the theatre and really enjoy the play ... " She lived another five years.

Freeman and Watts claimed 52 percent of their first 623 surgeries yielded "good" results, but they did not offer a clinical yardstick for what constituted an improvement. Patients often had to be retaught how to eat and use the bathroom. Relapses were common, and three percent died from the procedure. The most famous Freeman-Watts failure was JFK's sister, Rosemary Kennedy, who needed full-time care for 64 years (she died in Jan 2005).

Nevertheless, hospitals were willing to put up with lobotomies and all their shortcomings for no other apparent reason than post-operation lethargic patients were easier to care for than pre-operation emotionally-charged ones.

In 1967, Freeman performed a lobotomy on one of his original patients in Berkeley, California. He severed a blood vessel, and the patient died three days later. This effectively brought his career full circle. During the last five years of his life, he performed no more lobotomies. He died from cancer in 1972, age 76.

Today, according to the Washington Post, there are probably fewer than 20 brain operations a year (not lobotomies) in the US to treat psychiatric disorders, part of the negative legacy of Freeman that has scared away researchers and funders. [Update 10/27/09: Last year the FDA approved deep brain stimulation for OCD in rare instances and the procedure is being experimentally used for depression.]

In 1949, at Freeman’s urging, Moniz received the Nobel Prize. As S Nassir Ghaemi MD of Emory University in a review comments:

“It is quite ironic that in that same year, the Australian psychiatrist John Cade would discover lithium ... yet after the Moniz fiasco, the Nobel committee apparently has shied away from giving awards for direct treatment of mental illness, and thus the discoverers of lithium, antipsychotics, and antidepressants have never been duly recognized.”

One day that may change. But first the ghost of Freeman needs to be thoroughly lobotomized.

Monday, October 26, 2009

Mother Nature Speaks

I shot this from my iPhone, three or so miles as the crow flies from where I live, in rural Southern CA. What you are looking at is part of the devastation caused by the Cedar Fire of 2003. On the evening of Oct 25, a hunter set off a signal flare that ignited the dry brush. Night conditions prevented firefighting aircraft from making water drops. Then, around midnight, the very worst thing that could eventuate - eventuated:

The notorious Santa Ana winds were unleashed, fanning the flames like a blowtorch. In a matter of hours - six years ago today - the fire had moved 30 miles, burned 100,000 acres, and killed 12 people. In all, 280,278 acres were torched and 15 people lost their lives, including one fire figher, Steven Rucker. The fire was finally contained Nov 3, but it took till Dec 5 before complete control was achieved.

When I moved here in late 2006, I saw clear evidence of fire damage within two miles of our home, in three different directions. My housemate evacuated with his cat, not knowing if he would have a home to return to.

A mere four years following the Cedar Fire, this time in 2007, three different fires bracketed our community - this time from farther away - part of a series of fires that scorched a half-million acres from the Mexican border up to Santa Barbara, north of LA. Fortunately, this time, no lives were lost.

Those green shrubs you see in the foreground are baby oaks, part of the cycle of rebirth and regeneration. But two fires within four years may also signal system collapse, equivalent to global warming, an economic meltdown, or a nervous breakdown. Sustained dry conditions spanning two decades have weakened the mighty oaks and other trees in the region, making them prey for beetle infestation and other blights. Against a raging fire, these trees literally combusted. Then the Santa Ana carried their flames - across canyons, across freeways - into other vulnerable trees.

Moving walls of fire, the Red Wind, the Devil's Breath, just a couple of the names. Trust me, just a gust from the east this time of year is enough to strike the fear of God into everyone who lives in Southern CA. So far this season, the Santa Ana's have been quiet. We hold our breath, praying Santa Ana will hold hers. Then, hopefully, in two or three weeks, the rains will start, bringing this year's fire season to an end.

Hopefully, again, we will see more rain in years ahead. And hopefully, what we are witnessing is just part of the cycle of nature, not a complete system breakdown. Eventually, the earth will mend, but whether our species will be around when that happens is something we simply cannot predict.

Sunday, October 25, 2009


Today, I turned 60. Son of a bitch! Why me?

Back in July, I had a foretaste of old age. I woke up in my mom's house with my leg vibrating like a tuning fork and aching like a bad tooth. I gladly would have donated my leg to science, provided they were willing to take immediate delivery. I gritted my teeth as I suffered through her recollections about the fictitious middle child she thinks she mothered, the one who apparently couldn't wait to get on the school bus each morning to face a full day of being small and nerdy with glasses. Then I happened to mention my concerns about boarding my flight home the next day and six hours of being jammed into a seat. Her reply was shut up and stop complaining.

Seriously, mothers. Okay, if it wasn’t for her, I would have been calling a cardboard box home, but really, seriously ...

It turned out my leg cramp was a pinched sciatic nerve. I managed to soldier on for about a week, then the torture started in earnest, blinding shooting pain radiating from my buttocks to the sole of my foot. For eight days, I was flat on my back on the living room couch, staring up at the ceiling fan, cursing and screaming at God. God and I have issues.

Thankfully, a buddy stocked me up on grown-up baby food - Ensure, bananas, Gator Aid - and drove me to visits to the chiropractor. One day, the pain was not as bad as the day before. I was going to come out of it. But now when I walk down the street - an endeavor I no longer take for granted - and see old men and women hobbling about as best they can without complaint, well, let's put it this way, I'm not viewing them through the same stupid eyes.

I’m entering the decade where things fall apart, what a good friend refers to as old Chevy syndrome. You know, you’re happily tooling down the freeway and - clunk! - the trannie drops out or a wheel goes flying off and suddenly things are never the same. I’ve already been through my brain quitting on me. Now a whole leg. Add in my deforested head, failing eyes, nagging aches and pains, and back teeth that resemble broken crockery, and - let’s put it this way - pretty soon I’m going to require the services of a stunt double.

Last week, I talked about this with my psychiatrist. I pay for my visits, which means I get to talk for a full half-hour about things I want, rather than be rushed out the door after a drive-by ten-minute meds check. I’m not afraid of death, I told him. If I die I die, no big deal. But to endure the rest of my life in constant pain and fatigue, with vital bits and pieces not operational, with my brain failing to boot up. Year in and year out ...

I have two choices, I told him. I can grin and bear it or I can become a grumpy old man. It’s kinda like reaching acceptance with your illness, he concurred. You acknowledge reality and learn to accept your limitations. That way, life is only a constant challenge (which I gather is normal) rather than an interminable burden.

A few months ago, in an email, I joked to my daughter Emily that age is the biggest risk factor for everything that can go wrong with you. So don’t be stupid like me, I advised her - stay young.

But age does have its compensations. Three and a bit weeks ago, I became a grandfather. On a Skype connection, my daughter in New Zealand held up little Teddy, days old, to her webcam. My beaming face, in turn, landed on her computer screen. What she couldn’t make out, of course, were my tears of joy. Today I turned 60 and life is good.

Friday, October 23, 2009

Scott Gregory Hawkins - Who Will Speak Out?

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

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

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

Within an hour of posting my blog piece, I came across a news story that the US Senate that very same day had passed the "Matthew Shepard" Act that would help protect gays and lesbians from hate crimes. Matthew Shepard was a 21-year-old student attending the University of Wyoming. Eleven years ago, he was lured into a car, and subsequently robbed, beaten, and tortured, then left to die tied to a fence in the middle of nowhere.

According to witnesses, Matthew was targeted because he was gay.

Matthew's murder raised an immediate public outcry, not just from the gay community, but from all of us sickened by any display of hate and intolerance. The murder and subsequent trial was front page news, and received wall-to-wall coverage on all the news channels. The gay community made sure that Matthew would never be forgotten. Meanwhile, politicians and activists pressed for the passage of a hate crimes bill, which was finally passed yesterday, and which is awaiting the President's signature to become law.

Suddenly, it occurred to me. What about Scott? The only news coverage was local. There was no public outcry. No mental health advocates spoke out. No politicians or activists rushed in to propose a hate crimes bill to protect those with mental illness.

On the rare occasions when someone with a mental illness happens to commit a violent crime, we hear all about it. Front page news, lead story, shrill voices urging that innocent people need to be protected from us. But the hard cold truth is society preys on us. We are the ones on the receiving end of outrageous and violent acts. But no one cares about us. We are different, mental, crazy.

Scott had a mental illness that drew attention to his social awkwardness. His Aspergers set him up for ridicule and abuse and bullying. But instead of retreating into a shell, Scott gave to the community, he dared attend college to realize his dreams. Two days ago, in his own room, someone outrageously and irrevocably shattered those dreams.

Who will keep Scott's memory alive? Who will speak out on behalf of those of us with mental illness?

All I hear is silence. Silence. Dead silence. Silence kills ...

Thursday, October 22, 2009

Death of an Outsider

This headline appeared in today's Sacramento Bee:

Slain Student Was Gentle, Sometimes a Target, Dad Says

On Wednesday afternoon, Scott Gregory Hawkins, 23 and a transfer junior at Sacramento State, was killed in his dorm room. He had Aspergers, that "sometimes made him a target of bullies," according to the article. The Bee continues:

"He liked to talk on and on about his favorite subjects, especially history," his father said. "And he knew an amazing array of facts about Roman armies and World War I and World War II.

"And he hoped to specialize up there in Middle Eastern studies and Middle Eastern history. He liked (Sacramento State's) history program better than any other schools."

Again, according to his father:

"He loved that campus. He was extremely happy there. This is actually the happiest we've ever seen him in his whole life. He was just thrilled to get in there, to get into the new dorm there.

"He was just coming into himself, he was just becoming a really great person."

This particular story really hit me hard. Mental illness makes outsiders of all of us. Our odd behavior and social awkwardness virtually guarantees we won't be sitting at the table with the cool kids. Quite the contrary, we're the butt of everyone's jokes and fair game for the school bullies.

I'm sure Scott had far more challenges making it through a day at school than I ever had, but it was very easy for me to identify with him. Like Scott, I too was a history buff. Back in junior high, when others were talking about stupid junior high things, I would much rather talk about how Hannibal used his Numidian light cavalry to great effect at the battle of Cannae.

Only I had no one to talk to.

I was shy, socially awkward, nerdy with glasses, skinny, and the smallest kid in my class. Whatever made Lee order Pickett to lead a suicide charge up Cemetary Ridge into the teeth of Union artillery at Gettysburgh? I used to wonder.

Getting on the school bus everyday was kinda like that for me. I never stood a chance.

History did a lot for me. It helped me think expansively and speculatively. It got my mind oriented to all the "what ifs." It got me interested in politics, the arts, philosophy, literature, scientific discovery, invention. It exposed me to great individuals and extraordinary achievement. It inspired me. It uplifted me. It connected me.

I may have been an outsider, but my inner world was deep and rich. I can only imagine that is what it must have been like for Scott, as well. His parents drove him to college, so he could realize his dreams. But Scott was an outsider, a target for bullies.

As I said, this story really hit me hard.

Wednesday, October 21, 2009

Another Adorable Grandson Pic

Little Teddy, 3 weeks.

My Zombie State is Other People's Normal

On Saturday, I received an email from a friend:

"Two people have emailed me to see if you are alright. How would I know? Hypomania is rocket fuel for your work."

My blog was no busier than usual that past week, save for an animated comment thread. Okay, let's make that a really really animated comment thread. My immediate reaction was a defensive one. There they go again, I thought. Pathologize my behavior. Attribute every action of mine to my illness. Most of you have been on the receiving end of this - show the slightest sign of life, dare to crack a joke and actually look happy, and it must be hypomania. Bipolars are as bad as the general population - worse, far worse - in this regard.

I once emailed a friend with news that I had won a major international award, and, without offering her congratulations or even acknowledging my achievement, she replied that it sounded like I was hypomanic and I needed to be careful.

What the ... ?

Then I had to laugh. All the week before, I had been down for the count with flu symptoms. I had been sleeping 16 hours a day. I would emerge from the blankets only to walk about with the feeling of the inside of my head wrapped inside these very same blankets. I had no energy, I felt like someone three times my age, and my mood was in a slow glide south.

Trust me, had they been auditioning for a remake of Night of the Living Dead, I would have received a call-back for the lead zombie role. Yet, somehow, I had managed to crawl to the computer and crank out my standard quota of blog pieces (two involving the intricacies of diagnostic psychiatry), plus fire off a long round of zinger comments.

What gives? Yesterday, while out on a country walk (with a clear head!), I got thinking about my friend's email. It's easy, of course, to get a totally wrong impression when there is no face-to-face contact. But I could recollect no shortage of real life Twilight Zone experiences dating from way back.

For instance, in my college dorm room 40 years ago - again in a flu-induced zombie state - I responded to someone with a lame comment and the whole room cracked up. I got off a repeat rimshot-worthy one-liner, then another one. I was death warmed-over, but to the people in the room I was Don Rickles.

Twelve or thirteen years later - same state of zombie-hood - I was the steady hand who calmed down a room of anxious individuals. I could go on and on. Sometimes it's the flu. Sometimes it's depression. Sometimes, for no apparent reason, my head is not attached to the rest of my body. There are no guarantees. Often, when I feel out of it, I am really truly, totally utterly, out of it.

On the reverse side of the coin, when I am feeling on my game - that is when I need to watch myself. Frequently, I find myself looking at a sea of perplexed faces. And heaven help if I know I'm off my game and my anxiety takes over. You know those Southwest Airline ads: "Need to get away?"

Anyway, here I was, taking my walk, gazing out into the mountains, when it suddenly hit me in a flash:

My zombie state is the equivalent of other people's normal!

If I could only be a zombie, I could lead a normal life. Here's how it works:

Like a lot of you, I experience racing thoughts. Think of my brain as the UN General Assembly with an angry Khrushchev on every seat yelling wildly and banging his shoe on the table. But the flu or a depression or some kind of brain fog shuts down all those Khrushchevs in my head. There are no distractions. I can focus on the task at hand. I appear sharp and to the point. Of all the crazy things, I give the impression that I'm operating on rocket fuel.

All those Khrushchevs are the equivalent of too much stuff coming in - too much thought, too much emotion, too much sensory input. Since I happen to work in a field that places a high premium on creativity and intuition, I tend to regard this as a good thing. I need those Khrushchevs. They work for me, provided I can show them who's boss.

But too much of a good thing for me has a way of manifesting as bipolar or anxiety or panic or just plain weirdness. This is the downside of Khrushchev. Every once in a while, things get out of hand. For others, these Khrushchevs may show up as ADD, schizophrenia, some forms of depression, or just simply strange or inappropriate behavior.

These days, I am fairly confident in matching the right Khrushchev to the right occasion, so that what comes out of my mouth doesn't embarrass me. Far from it. These days, I actually get invited to places. Back in the old days, I could be counted on to pick the wrong Khrushchev, generally a strange weird specimen that had people backing slowly toward the exits.

What has changed over the years is that I have slowly learned to read subtle social cues and modify my behavior accordingly. I suspect this is true for most of you. These days, I feel fairly confident walking out the door. Back in the old days, I didn't risk it. I stayed indoors and isolated, which, of course, made me fair game for crushing depressions.

It's a strange world when showing up as a zombie shrouded in a protective depression is the state most likely to create the best impression for me. But when I'm feeling good, I often lack insight to know that I'm feeling too good for my own good. That's why I need to watch myself, and - more important - watch others.

"Knowing thyself" is central to "Knowledge is Necessity." Only through long introspection do we find answers and learn to ask the right questions. Consider this blog piece a long and involved question to all of you. I'm very interested in your answers. Please fire away by going to the comments below ...

Grandson Update

Little Teddy, three weeks old.

Tuesday, October 20, 2009

Thinking of Going Off Your Meds? - You Need to Read This First

Going off meds may be a sensible and responsible personal decision for you - with the emphasis on sensible and responsible. Tragically, too many of us opt for crazy and irresponsible. Whatever choice you make, first you need to be reading my friend Judy's book, which I very strongly recommend for anyone living with a mood disorder, including loved ones. This review first appeared on my website in 2005:

A sobering reminder of the heartbreak and hurt we can inflict on our partners comes through loud and clear in the poignant memoir by Judy Eron, "What Goes Up: Surviving the Manic Episode of a Loved One." Judy and her husband Jim, whom she had known for nine-and-a half years, were well on their way to realizing their dreams. They had uprooted from Tennessee to build their little hideaway in the desolately beautiful Big Bend region of Texas. There they planned to spend most of their time together in splendid isolation, but no sooner was their homestead ready for occupancy when Jim went off his lithium.

"It is a strange set of circumstances," Judy begins, "when a wife wakes up every morning wishing her husband would get severely depressed or arrested." Or has an automobile accident that sends him to the hospital or is caught running naked in the streets.

Anything that might take him out of his destructive mania.

By the time they reached Washington, their summer retreat from the Texas heat, Jim was already behaving strangely – first the pressured talking, then rudeness and impatience soon escalating into grandiosity, infidelity, dangerous behavior, and abuse. No one was going to tell Jim anything was wrong, least of all his wife.

Writes Judy: "If Jim had met another woman and fallen out of love with me, I could have coped somehow." Her life experience had at least prepared her for getting jilted by the proverbial blonde, but despite being a psychotherapist this was totally new. It was as if the mother ship had switched her loving and caring soul mate for an alien impostor somewhere out over the Texas desert. The eggshells she found herself walking on started to crack and she had no choice but to seek refuge in her friends and family.

Through an agonizing year she waited in vain for the crash that everyone said would happen or the 911 situation that would put him in the hospital. Or for Jim to come to his senses on his own. But the man she loved was far too in thrall to his "natural" self, even if that meant, ironically, trading his prescription drugs for recreational ones. Many a time Judy allowed herself to get her hopes up as the situation appeared it might resolve, only to end up bitterly disappointed. There was nothing she could do except take care of herself. Kay Jamison, herself, had told her exactly that. People in a state of mania, by definition, are out of control.

The book’s title implies that Jim must have come down. But we’ll never know that. He could have remained up. No one was around to see him crash. Judy assumes he must have, but mania has a way of turning on its victim, of creating an energized hell that leaves only one way out. One clear October day in the Texas desert – perhaps depressed, perhaps manic, most likely a combination of both - Jim took that only way out. It was an inevitability rather than a choice.

It was the Jewish Day of Atonement. At-one-ment. Jim had completed his tortured path to spiritual wholeness. For the woman he left behind, putting back the shattered pieces of her life was only just beginning.

Dealing With a Loved One’s Mania

Judy’s penultimate chapter is entitled "Woulda, Coulda, Shoulda." In a cruel twist of the knife, survivors inevitably end up blaming themselves for failing to respond with the impossibly precise measure of support, patience, compassion, confrontation, and tough love. As if they somehow foolishly left the eggs out of a recipe for baking a cake. In truth, Judy did everything she could have done, just like all survivors. There are no manuals, no guarantees.

Having said that, Judy does proffer some useful advice, based on her experience and research, principally:

  • You should not try to deal with mania by yourself. Forge a strong alliance with a psychiatrist and build a support network.
  • Know that you are dealing with someone out of control, who can no longer be trusted.
  • Be ready to take responsibility for being the decision-maker.
  • Look after yourself. Keep your life going.
  • Read as much as you can about the illness.
  • A manic person "will hammer on your weakest spots to bend you to his way of thinking, namely that he’s not sick."
  • "Without a doubt, you will be abused emotionally. You may decide to bail out … You are only human. Love is powerful, but in the face of mania, it is not all-powerful."
You can purchase What Goes Up at Amazon or go to her website.

Monday, October 19, 2009


Last weekend, a group of us rented a van and headed out to Edwards Air Force Base, scene of Chuck Yeager breaking the sound-barrier in the Bell X-1 in 1947. He did it again on Saturday, with an authoritative sonic boom, this time as a co-pilot in an F-16. He is 86.

Here are my home movies of the day. Enjoy ....

Sunday, October 18, 2009

David Healy: But Is It Depression?

In a recent (and still ongoing) series on Robert Spitzer and the DSM, I touched on some of the history of the difficulties in separating out the diagnosis of depression from both bipolar and anxiety (part of what Freudians used to call neurosis). A different historical perspective is offered by David Healy MD (pictured here) of the University of Wales. I originally published this in an email newsletter back in Nov, 2003, and it has been featured on my website since Dec, 2003:

Consider these scenarios: A patient back in the seventies complains of "nerves" or anxiety and is sent out the door with a tranquilizer (benzodiazepine) such as Librium or Valium. A few years later, that same patient might be asking for Xanax for her panic attack. In the mid-nineties, we have the same patient with the same symptoms telling her doctor she has depression. Today, the same patient is likely once again to complain about anxiety.

Much of the credit for how we understand ourselves goes to the pharmaceutical companies, even if we don’t take meds, David Healy MD of the University of Wales said in a grand rounds lecture at UCLA on Oct 28, 2003 and webcast the same day. Upjohn (since taken over by Pfizer) pioneered the concept of marketing the illness rather than the drug, capitalizing on the DSM-III’s reclassification of anxiety into several disorders to push Xanax for panic disorder. In the mid-eighties, as the benzodiazepines became a focus of concern, the SSRIs in development were first seen as non-habit-forming alternatives to tranquilizers before they were targeted to treat depression. More recently, the SSRIs are returning to their original purpose, with the drug companies spending up to $100 million a year to promote these meds as "anxiolytics" (thereby distinguishing them from the bad associations of tranquilizers).

A thorn in the side of the psychiatric establishment, Dr Healy is the author of "Let Them Eat Prozac" and a dozen other books, has published articles on the suicidal side effects that some patients can experience on antidepressants, has appeared as an expert witness in legal actions against Prozac and Paxil, and recently sued the University of Toronto for rescinding an employment offer. According to Dr Healy, in order to create new markets for its products, the pharmaceutical industry ghost-writes much of the literature that appears in mainstream psychiatric journals, mobilizes expert opinion, designs its own drug trials, engages in extensive media campaigns, and underwrites (and even establishes) patients’ groups.

Dr Healy stressed to this writer that he is not hostile to the industry, simply stating that its influence needs to be recognized.

During the 1990s, Dr Healy went on to say, we converted cases that would have been treated by Valium and Librium into cases treated by Prozac, Paxil, and Zoloft. Back in the 1960s, an Eli Lilly print ad for a tranquilizer showed a young mom playing with her daughter. Another Lilly ad from the same period, by contrast, displayed the face of depression as an elderly woman. Back then, he reminded his audience, depression was regarded as a rare illness affecting mainly older people. In 1996, when the World Health Organization reported that depression was the second greatest source of disability on the planet, the reaction from psychiatry was not how did society become depressed so fast, but rather "we’re the second most important people in medicine after the cardiologists."

But this trend was far from universal, Dr Healy pointed out. During the nineties, the Japanese did not become depressed the way we did. Prozac is not on the market there [Note: this has since changed], and tranquilizer use remains vastly greater than antidepressant use. Most of the rest of the world, Dr Healy reminded his audience, follows the Japanese model.

Which raises the $64,000 question: Are we better off with antidepressants? The answer may elude us, if we follow Dr Healy’s reasoning. Randomized clinical trials, he says, were never meant to prove a treatment works. Rather, they are designed to show something doesn’t work, as in the case of a charlatan promoting snake oil. It is industry’s "greatest achievement," claims Dr Healy, to turn this around. Although he does prescribe antidepressants in his clinical practice, one senses it is with the confidence of one recommending a Tylenol for unexplained pain than an antibiotic to knock out a particular infection. Indeed, he concluded, if SSRIs worked for depression or anxiety the way antibiotics do for GPI (syphilis), we wouldn’t have the illness around anymore.

Don’t expect this guy to be the guest of honor at any industry-sponsored symposia.


In his UCLA grand rounds lecture, and in an internet article, Dr Healy gave several examples of how pharmaceutical companies influence medical and public opinion. One of these involved the company, Current Medical Directives (CMD), which ghost-writes and coordinates medical articles for its clients. As part of a legal action against Pfizer, Dr Healy obtained access to a document that listed the progress of 85 articles on Zoloft. Two articles in preparation related to Zoloft and PTSD, for which Pfizer was seeking a license. The authors were listed as "TBD," for "to be determined." The articles eventually appeared in JAMA and the Archives of General Psychiatry, with several academic psychiatrists credited as the authors. In a study published in the British Journal of Psychiatry, Dr Healy found that the 85 CMD articles were cited three times more often than non-CMD Zoloft articles. One hundred percent of the CMD articles reported favorable results for Zoloft vs 44 percent of the non-CMD articles.

Another example involved six academic articles on pediatric depression, with the authors hailing Paxil as "effective, safe, and well tolerated," despite clear evidence of suicidal thinking and behavior in some patients, greater than those on the placebo and comparison drugs. Since then, citing the same data the academic authors had access to, authorities in the UK have advised against prescribing Paxil to patients under age 18 while the FDA in the US has announced strengthened warnings on product labeling.

Postscript: In 2004, following two highly-publicized public hearings, the FDA announced that black box warnings advising of increased suicidal risk for non-adults would appear on antidepressant product labeling.

Friday, October 16, 2009

This Just In: We Are Sheep

The events leading to this blog piece started out as a joke. A good friend of mine dropped “dihydrogen oxide” into a conversation. Call me the sharpest knife in the drawer, because after ten minutes and 800,000 laps around the frontal lobes, I instantly got it. Dihydrogen oxide - two atoms of hydrogen, one of oxygen - is “water.”

A quick Google search turned up its more sinister cousin, “dihydrogen monoxide” (DHMO), also known as “water.” The Dihydrogen Monoxide Research Division has discovered that DHMO, among other things, is the enabling component of acid rain, the causative agent in most instances of soil erosion, is present in high levels in nearly every creek, stream, pond, river, lake and reservoir in the US and around the world, has been verified in measurable levels in ice samples taken from both the Arctic and Antarctic ice caps, and been found in the devastating Indian Ocean tsunami in 2004 which killed 230,000 in Indonesia, Thailand, Malaysia. and elsewhere.

According to, back in 1997, Nathan Zohner, a 14-year-old student at Eagle Rock Junior High School in Idaho Falls, based his science fair project on "the dangers of dihydrogen monoxide." Forty-three of 50 ninth-grade students favored banning it. The prank was based on previous circulated hoax petitions.

In an earlier blog piece, I had fun with DHMO’s more benign cousin, dihydrogen oxide, also known as “water.” Spoofing Oprah’s predilection for featuring wacko fad cures on her show, I introduced "The Dihydrogen Oxide Cure: Nature's Boner-Popping Miracle Answer to Depression, Aging, Heart Disease, Obesity, Wrinkles, Memory Loss, Impotence, and Just About Everything, Totally."

Among other things, I noted that dihydrogen oxide is natural and is found in all of nature, accounts for 60 percent of our body weight, and that without it we would die and all life on this planet would cease. I noted that people were achieving miracle results drinking it and even bathing in it, and that you could buy this miracle nature cure from me for just four dollars a bottle.

Oprah, of course, loved it and invited me back on her show. (Not really, that was a joke.)

In the Penn and Teller clip above, from an episode from their ShowTime series Bullshit, the two magicians dispatch a woman to an environmental gathering to collect signatures for a petition to ban dihydrogen monoxide. Hundreds of people signed.

It was tempting for me to sneer at these gullible sheep until I realized it could have been me. In an instant, what had been a joke to me turned serious. Okay, let’s analyze the Penn and Teller piece:

The woman fit right in with the crowd and thereby didn’t arouse suspicion. These were people at an environmental event, primed to lend a sympathetic ear to an attractive and earnest woman wanting to save the planet. My guess is that an older man wearing a suit and spouting corporate jargon would have received no signatures.

I’m also guessing that had Penn and Teller dispatched a redneck to a gun show with a petition to ban the author of this highly inflammatory and un-American piece of rhetoric, “that whenever any form of government becomes destructive to these ends, it is the right of the people to alter or to abolish it,” that he would have collected as many signatures.

The author, of course, is Thomas Jefferson, and the quote is from the Declaration of Independence.

About four years ago, I was in the studio audience for a taping of the Food Network’s hit show, Emeril Live. A major part of the production involved priming the audience for Emeril’s grand entrance. Loud music was played, a comedian warmed us up, and a stage manager with paddles in both hands (the kind ground crews use to guide 747s to their berths) played us like a puppet on a string. I swear, by the time Emeril made his appearance, had he or anyone else affiliated with the show instructed us to take off our clothes and swear allegiance to Rush Limbaugh we would have done so in a heartbeat.

Remember those Nuremberg Rallies? Hitler and his henchmen were master psychologists.

I encountered the phenomenon in my previous incarnation as a financial journalist some 20 years back. In contrast to classic economic theory that posits that marketplace behavior is rational and self-regulating, nearly every day I ran into examples of irrational behavior and out-of-control events. The strange thing is that the same person who would spend an hour clipping coupons to save ten dollars on groceries would not hesitate to entrust a stranger with $70,000 of hard-earned savings he or she might never see again.

There are various terms for the phenomenon: mob psychology, group-think, and so on. The only cure is a highly-skeptical mind. The catch is, as the Penn and Teller piece so vividly illustrates, that we all tend to let our guard down in situations where we feel comfortable and with people we think we can trust.

Con men and rabble-rousers thrive in these situations. They see us as sheep. Think it can’t happen to you? That it has never happened to you? Replay the clip. If you believe in environmentalist causes: Would you, in that situation, have signed that petition? Alternatively, if you don't believe in environmentalist causes: Would you, at say a gas and oil industry convention, have signed a petition saying global warming is a myth? Be honest now.

Thursday, October 15, 2009

Is The Government Spying on Those with Schizophrenia Enough?

This from the Onion: The government needs to do more to help individuals with paranoid schizophrenia, such as implant devices in their heads so voices can tell them which bus drivers hate them and which manholes are covering up underground government prisons.

On a serious note, too many of us have bitter experiences of well-intentioned people charged with helping us doing the very opposite: Threatening restraints, not listening, telling us we will never work again, making us feel like outsiders ...

Have a good laugh, then when you're through laughing ...

Wednesday, October 14, 2009

Rerun - Where Dumb Psychiatry Meets Dumb Antipsychiatry

Yesterday, in Part V of Spitzer and the DSM, I discussed at length how a major error in the DSM-III of 1980 has gone uncorrected for 29 years. This concerned separating out "recurrent depression" from bipolar, to which it is a close cousin, and lumping it with "chronic depression." As a result, many in the bipolar spectrum are misdiagnosed and spend years leading miserable lives on one failed antidepressant after the other. In light of two reader comments to yesterday's piece and the importance of the issue, I thought it appropriate to republish this from February:

In my last blog, I urged that we consider issues in terms of "smart vs dumb" rather than "pro vs anti." In the final analysis, dumb psychiatry and dumb antipsychiatry serve the same master. Let me give you an example:

For at least three decades, it has been widely accepted that prescribing an antidepressant (with no mood stabilizer) to someone with bipolar runs a strong risk of flipping a patient into mania or speeding up the cycle or both. The American Psychiatric Association in it's 2002 Practice Guideline for treating bipolar issues a blanket warning against this practice.

The catch is that it is often difficult to distinguish unipolar depression from bipolar depression. The result is that too many of us with bipolar are misdiagnosed with unipolar depression and prescribed meds that make us worse.

There is an additional twist to this catch: Many people experience "recurrent" and "highly recurrent" depressions that come and go in a pattern very similar to bipolar cycling. The pioneering diagnostician Emil Kraepelin observed this phenomenon way back in the early twentieth century.

When Kraepelin coined the term, manic-depression, he wasn't merely referring to bipolar. He also included those with recurrent depression. This was the widely accepted view until the DSM-III in 1980 separated out bipolar and lumped recurrent depression with "chronic" depression.

The result is that doctors tend to treat all depressions alike - with predictably disastrous results. This is an example of "dumb" psychiatry, the indiscriminate prescribing of antidepressants to anyone who happens to say they're depressed.

Reformers in the profession, such as former head of the NIMH Frederick Goodwin MD and Nassir Ghaemi MD of Tufts, have long urged that psychiatrists think twice before prescribing antidepressants. The best way to turn certain unipolars into bipolar, they would argue, is to prescribe an antidepressant.

Dr Goodwin and a good many others have campaigned for years to realign the next DSM so that it is more closely in tune with Kraepelin's original conception of manic-depression. This would get doctors to rethink their prescribing practices.

We don't know if change will happen. But no doubt the task force charged with issuing an updated DSM is considering the matter. Indeed, the possibility of a new "bipolar III" diagnosis was the basis of a blog post last week from Furious Seasons, fairly typical of antipsychiatry sentiment:

I think it's been a boon to doctors - who get a patient for life - and Big Pharma - which gets a long-term customer - but I have my doubts about how useful the depression-is-bipolar thing is for patients who wind up on an atypical and an anti-seizure drug when they are dealing with something that's not even in the ballpark of mania.

To respond in brief:

Yes, big pharma would love a customer for life, but to make a case for a drug industry conspiracy one would have to bend time a hundred years. Kraepelin wrote his classic text, "Manic-Depressive Insanity and Paranoia," decades before drug manufactures came up with the first psychiatric meds, and psychiatrists have been arguing ever since where best to carve nature at its joints.

Moving on, bipolar is more accurately a cycling illness, not a polar illness. So is recurrent depression. Thus "something that's not even in the ballpark of mania" is irrelevant. The purpose of treatment is to manage the cycle, bring it under control, not necessarily treat symptoms at one pole or the other.

An antidepressant may work in some patients with recurrent depression. But a logical first option is to consider using a mood stabilizer such as lithium or Depakote or Lamictal.

Once the cycle is under control, it may be possible to consider low-meds or no-meds options in conjunction with cultivating cognitive skills such as mindfulness.

Admittedly, Lamictal had a lot to do with drawing attention to "soft bipolar" several years back, and GSK profited handsomely. But these days the drug has gone generic, along with lithium and Depakote. Thus GSK and others have no financial stake in pushing for an expanded bipolar diagnosis.

If anything, an expanded diagnosis would significantly reduce antidepressant sales. This is why you don't see drug companies sponsoring clinical trials to prove Drs Goodwin and Ghaemi right.

No doubt, some manufacturer will try to jump on the bandwagon with some implausible claim trumpeting the virtues of their house antipsychotic, only to be laughed out of town. But this would be an example of opportunism, not hatching a conspiracy.

As for psychiatrists wanting a patient for life: The best indication is that psychiatrists are driving away their patients. Only a small minority of patients adhere to their meds over the long term. Matching the right meds to the right diagnosis might change this.

So now we return to the issue of smart vs dumb. Dumb psychiatry treats all depressions as the same. So does dumb antipsychiatry. Dumb psychiatry favors preserving psychiatry's status quo. So does dumb antipsychiatry. Ironic, isn't it?


For how I abandoned my ex-wife that I mooched off of for years and other high-crimes and misdemeanors while the crusading Philip Dawdy was busy saving the world, check out this entertaining piece of fiction from Furious Seasons.

Tuesday, October 13, 2009

Spitzer and the DSM - Part V

Earlier installments in this series framed the creation of the modern DSM in terms of Kraepelin vs Freud. But is that truly accurate?

Robert Spitzer’s achievement represents a Nobel-worthy leap forward in the history of psychiatry, but his DSM-III was only meant to be a first installment to a work-in-progress, not frozen in time as psychiatry’s diagnostic Bible. Its present incarnation as the DSM-IV-TR of 2000 is essentially the same old 1980 book in a new cover.

There are many dangers to this. One of them is that the universal success of the DSM has entrenched its original errors. What may have started out in 1980 as a descriptive trial balloon by 1984 was unaccountably accepted as scientific fact, which by 1990 was regarded as wisdom of the ages. Now, in 2009, thanks to all the stake-holders invested in the status quo - insurance companies and so on - undoing these mistakes borders on the impossible.

For instance, a pharmaceutical company with billions riding on a new antidepressant does not suddenly want to find out that depression no longer means what it used to mean.

Previously, I pointed out that Spitzer was inspired by the pioneering German diagnostician Emil Kraepelin, who was born the same year as Freud. Unfortunately, Kraepelin was undoubtedly rolling over in his grave when the DSM-III was published. This is not an esoteric debate. The health and safety of anyone who has ever been depressed is riding on an accurate diagnosis, and unfortunately the DSM guarantees that won’t happen for a good many people.

It was Kraepelin who coined the term, manic-depression, but what he meant by the term was not a simple synonym for what we later called bipolar disorder. By manic-depression, Kraepelin also meant what we now call unipolar depression. Unipolar and bipolar could not so easily be separated out.

A later generation of researchers (including Jules Angst) did find a sizable exception. These were individuals who suffered from long-term and relentless “chronic” depression. These depressions contrasted with those who cycled in and out of their shorter-term “recurrent” depressions. To Kraepelin, recurrent depression and what we now call bipolar were part of the same manic-depressive phenomenon.

Contrary to conventional wisdom, an astute clinician does not need evidence of a manic episode to suspect bipolar in a patient. A history of recurrent depression is cause to probe for further indicators. Keep in mind, a patient never walks into a psychiatrist’s office complaining that he is feeling better than usual. Also keep in mind that when depressed, our brains trick us into forgetting what is was like to feel good, or, for that matter, too good for our own good.

Thus, unless a family member is present to remind her loved one to tell the doctor about the time he got a speeding ticket driving home from karaoke night with someone who wasn’t his wife, all the clinician has to go on is the patient’s current condition, along with his tale of woe.

During the seventies, expert opinion - led by Frederick Goodwin and David Dunner and others - favored Kraepelin’s approach. No matter how one chose to slice and dice manic-depression, the thinking went, it was crucial to draw a line between chronic and recurrent depression, and to recognize recurrent depression, at the very least, as a close cousin of bipolar.

So what happened? Spitzer and company did the unthinkable. They separated out recurrent depression from bipolar and lumped it with chronic depression. In addition, unless an individual cycled up into an extreme mania, he or she was deemed to have unipolar depression. (It took 14 years to get “bipolar II” with its less stringent hypomania threshold included in the DSM, and a strong body of expert opinion contends this does not go nearly far enough. Today, ironically there is extremely misinformed commentary that bipolar II is some form of new and unauthorized "expanded" version of bipolar. )

The result is that unless a patient is bouncing off the walls and ceilings, he or she is bound to be incorrectly diagnosed with major depression and be prescribed an antidepressant (this happened to me), which tends to worsen the condition. For those with bipolar II, a correct diagnosis is virtually impossible. Their lot is typically the frustration of years of antidepressants that don’t work or make them feel worse.

As for those with recurrent depression, forget about it. So might a mood stabilizer work on this population? Decades ago, lithium pioneer Mogens Schou found promising evidence. But thanks to the DSM, further research in this direction has been strongly discouraged, with pharmaceutical companies typically viewing all depressions as the same. (A notable exception was GSK testing Lamictal on a recurrent population.) Thus, we know that any given antidepressant will have some benefit on 50 percent of those who are depressed. The catch is we have no idea which 50 percent.

We can go on and on about all the DSM screw-ups just within the depression-bipolar sphere - its highly restrictive view of “mixed” states, its failure to account for anxiety symptoms, its bias toward finding depression in women - but let’s stop here. It’s enough to say the DSM, for all its good intentions, fails much of those deemed mentally ill much of the time.

Go to nearly any mental health website (not mine), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria (as in the screenshot on top). Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time. Spitzer, in the end, proved far too successful for our own good. But the fault lies with his successors, who failed to take corrective action, not necessarily with Spitzer.

Spitzer was a mold-breaker who inadvertently created a dogma as stifling as the Freudian Reign of Error he overthrew. What we now need to break the stranglehold of the Spitzer legacy is another mold-breaker - another Spitzer.

To be continued ...

Previous installments in this series:

Part I
Part II
Part III
Part IV

Monday, October 12, 2009

Spitzer and the DSM - Part IV

In Part I, I introduced Robert Spitzer, architect of the ground-breaking DSM-III of 1980 and what psychiatry was like when Freud ruled the roost. Part II described the Spitzer's triumph in unseating Freud, and Part III recounted Dr Spitzer's boorish behavior at the dinner table at the 2003 APA in San Francisco. To pick up where I left off ...

Yet when I surveyed all that my hands had done
and what I had toiled to achieve,
everything was meaningless, a chasing after the wind;
nothing was gained under the sun.

- Ecclesiastes 2:11

Nearly two years later, the Spiegel profile in The New Yorker gave me an insight into Dr Spitzer’s table manners. According to the piece:

Despite Spitzer’s genius at describing the particulars of emotional behavior, he didn’t seem to grasp other people very well. Jean Endicott, his collaborator of many years, says, “He got very involved with issues, with ideas, and with questions. At times he was unaware of how people were responding to him or to the issue. He was surprised when he learned that someone was annoyed. He’d say, ‘Why was he annoyed? What’d I do?’ ”

Then, following the runaway success of the DSM, things apparently went to his head. According to the New Yorker, “emboldened by his success, he became still more adamant about his opinions, and made enemies of a variety of groups.”

And again:

“A lot of what’s in the DSM represents what Bob thinks is right,” Michael First, a psychiatrist at Columbia who worked on both the DSM-III-R and DSM-IV, says. “He really saw this as his book, and if he thought it was right he would push very hard to get it in that way.”

This sense of ownership cost Spitzer his chance to head up the DSM-IV. The new chair, Allen Frances MD of Duke University, put his committees on notice to cut back on “the wild growth and casual addition” of new mental disorders. In a piece published in the June 29, 2009 Psychiatric Times, Dr Frances appeared to be bragging about how little the DSM-IV task force actually accomplished:

“In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III ...”

This is one hell of an admission. Basically, Dr Frances is telling us that the diagnostic psychiatry of 2009 is based on a book that was published in 1980, back when psychiatric science virtually didn’t exist.

It is speculative to ponder on the “what-if’s,” but that’s my job. So, suppose Dr Spitzer hadn’t fallen in love with his 1980 opus. Suppose he possessed some rudimentary people skills. Suppose he had been able to combine his innovative brilliance with a sufficiently level head to guide the DSM into its next critical phases - to fill in the blanks from the earlier editions, correct obvious errors, and realign content in accord with new scientific discovery and clinical insight.

Imagine, in effect, if you could pick up a current DSM right now and open the pages to an accurate description of your clinical reality. That book doesn’t exist. The DSM-IV is a dinosaur, and any clinician who relies on it as an authority is endangering his patients.

Things could have been a lot different. But the man who - through his superhuman efforts - unseated that twentieth-century icon Freud, through his own mortal foibles, wound up unseating himself. His personal disappointment turned out to be our huge loss.

To be continued ...

Saturday, October 10, 2009

Robert Spitzer and the DSM - Part III

In Part I, I talked about finding myself at a dinner table at a symposium at the 2003 APA annual meeting with Robert Spitzer, who masterminded the ground-breaking DSM-III of 1980. Part II touched on the history of the conflict between diagnostic and Freudian psychiatry, and the triumph of Spitzer’s DSM-III. To continue ...

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. And here I was looking up from my salad trying to think of something to say.

Out of deference, I waited for the psychiatrists at the table to open the conversation. I would just be a fly on the wall. But no one spoke. Silence. Just the clinking of glasses and the rattling of plates. I always knew psychiatrists were a bit weird, but this was ridiculous.

I introduced myself to Dr Spitzer as a bipolar patient who was at this particular conference as a journalist. These days, I simply introduce myself as a journalist. Back then, I over-identified with being an entry in Spitzer’s diagnostic schema.

Let’s put it this way, if you are in a constant life-and-death struggle with testicular cancer you are understandably thinking about it every second of your life. But then comes a time when you need to forget that you have one testicle and start focusing on your own personal Tour de Life.

But, yes, I still wear a yellow and blue DBSA rubber wristband, not unlike the yellow cancer band that Lance Armstrong made famous.

Anyway, I had a few thoughts of my own about the DSM, I told Dr Spitzer. Would he be interested in hearing them?

This is like telling Einstein that I had a few thoughts about relativity, but Dr Spitzer indicated that I proceed.

What motivated me to ask in the first place was that I naively assumed that the very last person to regard the DSM to be cast in stone would be the person who broke the mold in the first place. Think of Robert Spitzer as the great auto designer Harley Earl, and the DSM-III of 1980 as the 1955 Chevy and the DSM-III-R of 1987 as the 1957 Chevy.

By contrast, the post-Spitzer era - the DSM-IV of 1994 and the DSM IV-TR of 2000 - merely played around with the fins. So now, here we were in a new millennium driving around to the mechanics of a bygone era

Mind you, at the time I lacked the both the standing and the knowledge to challenge Spitzer on this, so I decided to stick to the one aspect of the DSM that I had put some thought into. This concerned the issue of gender and depression. Here, I was on fairly solid ground, as many experts were pushing for changes to the DSM on this matter. My view, and the view of these experts, is that the DSM symptom list is biased toward picking up depression in women while men suffer in silence. According to conventional wisdom, twice as many women experience depression as men. But a bit of tweaking to that symptom list, I argued, could even out that equation.

I waited for the go-ahead, then proceeded down the list. Symptom one is “depressed mood most of the day,” and the unfortunate example is “appears tearful.” Men, by contrast, express themselves in other ways or else fail to express themselves at all. Number three concerns weight gain or loss. Think of what women go to the fridge for when feeling low. Now think of what men reach for. Symptom seven is about worthlessness and guilt, but men tend to lash out and blame others. Last but not least is suicidal thinking. Men fall victim more often than women, but women make far more attempts, and so are more likely to come to the attention of the profession and be treated.

Dr Spitzer pondered my comments, then, as psychiatrists are wont to do, said nothing. By now, the main course had come out. Any further conversation was light and inconsequential. Soon the first of several speakers started talking. It was time to go to work, to take notes.

Two hours later, the last of the speakers wrapped up. Question time was just ahead. Most members of the audience use this brief interval to leave, and so it was that Dr Spitzer got up to make his exit, but not before addressing me.

“I thought about what you said,” he told me, or words to that effect. And then his verdict: “And I don’t go along with any of it.”

Then he rose from his chair and was gone.

Hey, what did I know? He was Robert Spitzer, founder of modern psychiatry. I was just a male bipolar patient who had to deal with depression every day of my life.

Friday, October 9, 2009

Rerun - Is Bipolar Cool?

Here's a piece I did in January that warrants a second look:

Something major has happened in the ten years since I've been diagnosed with bipolar. Back then, it was an illness you concealed. It was a shame you hid. Friends, family, and colleagues had a way of only seeing the diagnosis, and what they chose to see was not good.

To disclose your diagnosis was to risk everything: friends, relationships, livelihood.

Then something started to change. Over time, bipolar morphed into something that could be "cool" to have. Mind you, those struggling mightily with their illness saw nothing cool about it. Neither did their suffering families. But the flip side was the stigma was diminishing, and this had to be good news.

Part of the trend had to do with the recent recognition of bipolar II and various forms of "soft" bipolar. In other words, bipolar wasn't an all-or-nothing disease. You could be a "little bit" bipolar. And a little bit was cool. Even the way-out-there bipolars could make a claim to cool.

Van Gogh, Hemingway, Woolf - how cool was that? Okay, they all killed themselves. But maybe if they were alive today - the thinking goes - that wouldn't have happened.

Over the years, I have urged individuals to embrace their entire illness - the good as well as the bad. If we simply viewed ourselves as patients who suffered, I kept saying, we would always wind up stuck well short of recovery.

Last night, I went to Facebook and searched under "bipolar." If the word appeared anywhere on a profile page that a member created, Facebook would find it for me.

My results revealed "more than 500" finds. I suspect many thousands. There were a great many examples to choose from, but let's go with three:

First, there were those whose lives seemed part of a weird Andy Warhol movie. These weren't exactly people you would be seeking out as Facebook friends. Then again, their bipolar credentials carried an air of exclusivity, as if to challenge the world. In the past, these people would have been shamed for failing to meet the standards of society. Now, there was an air of pride and defiance. They weren't about to please you. You had to please them. Too bad if you weren't good enough.

Then there were young hotties who advertised themselves as a bit on the wild side. Most of them, I suspect, had never seen a psychiatrist. But they proudly proclaimed themselves as "semi-bipolar" or "must be bipolar." Forget for the time being the dangers of romanticizing one of the worst illnesses on the planet. Instead, focus on the fact that these young women - part of a new generation - view bipolar as something positive, as a credential they can use (and misuse) to make new friends.

Finally, there were those I like to call bipolar role models. The image that stuck with me is that of a very attractive woman in her thirties or forties. She is in a smart pants suit, in stylish heels, posing in front of her Cadillac Escalade. I'm bipolar, is the underlying message, and not only am I making it in your world, I'm really kicking ass.

These are just some of the new faces of bipolar. They are a reflection of a changing world, a world that they (we) are changing. It is the face of a new bipolar cool.

A new generation - the Facebook Generation - is out there, in your face. They are not hiding in the closet. For good or bad, they are wearing their bipolar as if it were something to be embraced and envied rather than an entity to be feared and despised.

The rest of society is likely to embrace this change, as well, but possibly at the expense of being indifferent to our pain.

In the meantime, we are looking at tons of upside. Here's hoping ...

Thursday, October 8, 2009

A Brief History of Mental Illness

I wrote this for HealthCentral's BipolarConnect. Following is a brief extract:

790,000 BC, give or take a few years
- Discovery of fire. Anyone crazy enough to take a burning tree into their cave and find a practical application had to have been dealing with bipolar. So, you nonbipolars out there, listen up: We give you the gift of civilization, and how do you thank us? That’s right. You marginalize us. (By the way, sorry we couldn’t get fire to you sooner.)

2000 BC - Ancient Egyptians view mental illness symptoms as physical, caused by disorders of the heart.

400 BC - Hippocrates and fellow ancient Greeks explain physical and mental illness in terms of “the four humors.” Melancholia literally means “black bile,” a condition Aristotle assigns to Socrates. Later, Galen refines the humors into “temperaments.” Bottom line: Mental illness is considered biological.

Second century AD - Aretaeus of Cappadocia links mania to melancholia, thus effectively identifying bipolar.

410 AD - Alaric and his Visigoths sack Rome. Dark Ages officially begin. Christian belief interprets mental illness as a sign of divine punishment or Satanic possession. This “fault principle” permeates treatment of the mentally ill to this very day.

Middle Ages - One of the treatments for mental illness includes drilling holes in the skull to allow evil spirits to escape.

1242 - The Order of Mary of Bethlehem establishes a shelter for the insane in London, referred to as “Bedlam.”

1492 - Christopher Columbus has a crazy idea and sails to the New World. To nonbipolars: We introduce to you to the concept of America, and how do you thank us? Yeh, right. (Sorry we couldn’t find it for you sooner.)
Read the rest of the piece here ...

Tuesday, October 6, 2009

Age Seven with Schizophrenia

Several months ago, in reference to a sensationalist TV segment that portrayed bipolars as killers and for other crimes and misdemeanors, I referred to Oprah as “an unmitigated idiot and a menace to society.” I take it back.

Yesterday, Oprah aired, “The 7-Year-Old Schizophrenic.” I didn’t see the actual episode, but her website contained four short videos, plus two articles, that sympathetically and with great sensitivity portrayed seven-year-old Jani Schofield and her parents, Michael and Susan.

Back in July, in the wake of an LA Times piece, I ran an equally sympathetic piece on Jani and her family, noting:

Jani has been diagnosed with schizophrenia, which usually breaks out in late teenhood-early adulthood, nearly always preceded by years of strange and erratic (and often brilliant) behaviors. From the very beginning, Jani hardly needed to sleep. At age 3, the tantrums began. At age 4, her IQ was tested at 146 (genius level). At age 5, her rages became violent. In his blog, Michael admits to both he and his wife Susan striking back, as well as taking away her toys and even "starving" her. The antipsychiatry community, ignoring everything else, jumped all over this as the true cause of Jani's condition.

Meanwhile, Jani's one or two invisible friends expanded into a psychotic community, along with hallucinations and delusions. Attempts at kindergarten and first grade failed. Last fall Jani tried to jump off a second story balcony. Autism? Bipolar? Doctors had no answers. Earlier this year, a medical team at UCLA issued their verdict - schizophrenia.

In the Oprah videos, Jani and her parents tell their own stories. We see a highly personable Jani describing her hundreds of imaginary friends and their make-believe world (real to her) called Calalini. She articulates her uncontrollable rages and racing thoughts and tendencies to violence, as well as the Clozaril and lithium she is on.

We see Michael and Susan talk about having to raise two children in two separate apartments, both for their own safety and to give one parent a break. We hear how the services Jani needs are unavailable. According to the main article:

At night, Michael and Susan find peace, knowing Jani survived one more day. Michael says this is his favorite time. "[I think]: 'We've kept her alive. We have now about 10 hours of rest until we've got to do it all again,'" he says. "And we will probably have to do it all again for the rest of our lives."

In my original blog piece, I concluded:

On Sunday, Michael posted, Hopefully, This Will Be Jani One Day, with a link to the biography of Elyn Saks. Elyn Saks is the author of the highly-acclaimed "The Center Cannot Hold," which documents her struggles with schizophrenia and her road to conditional recovery. Elyn Saks holds a masters in philosophy from Oxford, is a professor of law at USC, and is on the verge of attaining a qualification in psychoanalysis.

Says Michael: "Saks’s story gives me hope that one day Jani will be able to tell her own story."

Check out Michael's extremely candid and moving blog, January First.

Robert Spitzer and the DSM - Part II

In Part I, I mentioned how I found myself seated next to Robert Spitzer, the architect of the ground-breaking DSM-III, and the inadequacies of the earlier versions. To pick up where I left off:

In an article published in Science in 1973, Stanford University psychologist David Rosenhan described dispatching eight healthy associates to various mental hospitals, each claiming to have heard voices. All eight were admitted, seven with the diagnosis of schizophrenia, one with manic-depression.

Following admission, all eight behaved normally. Although many of the real patients suspected a ruse, hospital staff interpreted even routine behavior on the part of the impostors as pathological, such as “writing behavior.” To obtain release, the “patients” had to acknowledge their diagnosis and agree to take meds. The “patients” were held on average for 19 days.

In the second part of his experiment, Dr Rosenhan let it be known at a particular hospital that more fake patients were on the way. The hospital was aware of the results of the first experiment, and were confident they could weed out the impostors. Out of 193 patients, 41 were singled out as phonies and another 42 were considered suspect. In reality, no bogus patients had been dispatched. All the patients were genuine.

According to Dr Rosenhan: “Any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.”

A year later, Robert Spitzer MD of Columbia University drew the assignment of leading a new revision of the DSM, the so-called diagnostic Bible that no one paid any attention to at the time.

Dr Spitzer drew his inspiration from the pioneering German diagnostician, Emil Kraepelin (pictured here), who was born the same year as Freud. It was Kraepelin who coined the term, manic-depression and separated out the illness from schizophrenia, thus giving psychiatry a basic navigating system. Kraepelin believed that mental disorders were best understood as analogues of medical disorders.

In other words, you don’t treat a heart attack as if it were cancer, or as if the two were somehow related. For one, an individual in the throes of cardiac arrest and someone with a specific organ system under siege have entirely different symptoms.

But psychiatry, which back in the seventies was still in thrall to Freud, viewed things totally differently. To Freud’s followers, symptoms (such as depression) were merely maladaptive reactions to inner turmoil. You didn’t treat the depression; you dug deeper to root out the underlying neurosis. To a Freudian, diagnostics didn’t matter.

The old-timers have no end of horror stories. At the 2004 APA in New York, I heard Jack Barchas MD of Cornell University - the man who pioneered research into serotonin’s connection to behavior - relate how an early mentor actually challenged one of his ideas on these grounds: “How is this justified in the writings of Freud?”

Dr Spitzer lined up support from the one university of the day not under the spell of the Wizard of Id, Washington University (St Louis), an outpost of intellectual sanity fairly crawling with Kraepelinians. In 1972, John Feigner, then a resident there, came up with a classification scheme that Spitzer adopted as the template to block out a first draft, which was completed in a year. In addition, Spitzer used his unlimited administrative control to establish 25 committees peopled with psychiatrists who despised Freudian dogma and who viewed themselves as scientists.

The catch was that there was precious little that could pass for psychiatric science at the time. Meetings often degenerated into free-for-alls where the loudest voices tended to prevail. Nevertheless, a working draft was thrashed out, which was tested by the NIMH for reliability. In other words, if presented with a basic set of symptoms, could different psychiatrists agree on the diagnosis? Or, at least, kinda come close?

One problem in the past was that one psychiatrist’s view of depression could be very different from that of another psychiatrist. Dr Spitzer’s solution was the “checklist,” something we all take for granted these days. (For instance, a diagnosis of major depression requires checking off at least five of nine listed symptoms.)

Something else we take for granted: ADD, autism, anorexia nervosa, bulimia, panic disorder, and PTSD - these illnesses and others debuted during Spitzer’s watch, and no one these days seriously challenges their legitimacy.

Finally, a “multi-axial” system separated out major mental illnesses (such a depression, bipolar, anxiety, and schizophrenia) from personality disorders such as borderline personality disorder (which made its debut in the DSM-III).

The draft copy that got circulated amongst the profession totally eliminated that Freudian article of faith, “neurosis.” To Spitzer and his task force, neurosis was an emperor with no clothes. Basically, if depression were a reaction to neurosis, then show me the neurosis. The depression was visible, tangible, treatable. But what was this underlying neurosis crap? Where was the scientific evidence?

By the end of the seventies, Freudians were in retreat, but they still had the clout to sabotage Spitzer’s efforts. The term, neurosis, was restored, but relegated to parenthesis. In 1979, following some more strategic compromises, the DSM-III came up for approval before the APA. According to an eyewitness account from an article by Alix Spiegel in the Jan 3, 2005, New Yorker:

“People stood up and applauded. Bob’s eyes got watery. Here was a group that he was afraid would torpedo all his efforts, and instead he gets a standing ovation.”

The DSM-III became an instant runaway success worldwide. Finally, no more Freudian muck. Clinicians, researchers, and other stakeholders had a common language, could actually talk to one another. Patients for the first time could enter a clinician’s office with the reasonable expectation of an accurate diagnosis and the appropriate treatment. Imagine that.

And here was the man responsible for it all - arguably the most influential psychiatrist of all time - seated right next to me. What do I say?

To be continued ...