Friday, February 26, 2010

My DSM-5 Report Card: Grading Bipolar - Part IV

Part I, Part II, and Part III to Grading Bipolar placed heavy emphasis on that largely unmapped middle ground where bipolar bleeds over into clinical depression. Why this is critically important is that clinical ignorance leads to misdiagnosis and wrong treatments, which translates into years and even decades of unnecessary suffering.

The current DSM abets numerous opportunities for bad psychiatric practice, which the DSM-5 was supposed to redress. Unfortunately, the Task Force and its various workgroups suffered an extreme outbreak of dereliction of duty.

So, can the DSM-5 do better where bipolar bleeds over in the other direction into schizophrenia? First a little background ...

Back in the early twentieth century, the pioneering diagnostician Emil Kraepelin separated out “manic depression” (bipolar and recurrent depression) from “dementia praecox” (schizophrenia). This distinction provided psychiatry with its first real navigational aid, which continues to guide diagnostic practice to this very day.

But Kraepelin also recognized the limits to making a clear categorical split, and recent genetic findings are backing his reservations. Virtually all the leading candidate genes for bipolar happen to be leading candidate genes for schizophrenia, as well.

The current DSM recognizes some of the crucial fine shadings. Thus we have “with psychotic features” as specifiers to both major depressive disorder and bipolar disorder. In addition, there exists the separate diagnosis of “schizoaffective disorder” that is widely interpreted as a hybrid between bipolar and schizophrenia.

The issue: Should those charged with the DSM-5 attempt to fix what doesn’t appear to be broken? Or is there considerable room for improvement?

On with the grading ...

Psychosis, a Clear Definition

The current DSM makes various references to psychotic features, but what precisely is “psychotic”? To find out, one needs to flip the pages to the rather obscure diagnosis of “brief psychotic disorder,” which mandates one or more of the following symptoms:

Delusions; hallucinations; disorganized speech; psychomotor symptoms, including catatonic behavior.

The DSM-5 would leave this unchanged.

Fine, that provides a breakdown of the component parts to psychosis, but what is psychosis? The glossary to the DSM-IV concedes that none of the historic definitions “has achieved universal acceptance.” Narrowly viewed, psychosis refers to hallucinations and delusions to which the patient lacks insight. A wider view would incorporate patient insight. Still wider are the symptoms listed for the positive symptoms of schizophrenia (same as for a brief psychotic episode) and wider still would incorporate “loss of ego boundaries or gross impairment in reality testing.”

The current DSM punted in coming up with an authoritative definition and set of distinctions. It appears the DSM-5 is similarly opting out.

Grade: F.

With Psychotic Features

Psychosis looms large in mania and less so in depression. The DSM-IV operative term is “with psychotic features,” which the DSM-5 would leave unchanged. Presumably, a “feature” is less intense than a “symptom,” but it would be helpful to see this spelled out. Is this asking too much? Apparently yes.

Grade: F.

Mood Congruent/Incongruent

When adding a “with psychotic features” specifier to depression or mania, the DSM-5 would mandate clinicians to differentiate “mood congruent” from “mood incongruent.” In a depression context, mood congruent psychosis might translate to, say, irrational feelings of deserved punishment. A manic context might involve delusions of a special relationship to a deity.

Mood incongruent, by contrast, involves no apparent linkage between mood and disordered thinking.

The current DSM buries this distinction way back in Appendix C. Moving this up front and center is a major step forward. But will clinicians have to flip to the back pages to find the definitions?

Grade: B.

How Psychotic is Psychotic?

We know we can have a mood disorder “with psychotic features.” What is unclear is whether we can have a mood disorder with full-blown psychosis. Or is that something else? Say schizophrenia or schizoaffective disorder?

Misinterpreting psychosis leaves no room for error, as a diagnosis of schizophrenia sends (very wrongly) a clear message to abandon all hope.

Grade: F.

Schizoaffective Disorder

The DSM-5 spells it out: “The current DSM-IV-TR diagnosis schizoaffective disorder is unreliable.”

To start, the current DSM classifies schizoaffective under “Schizophrenia and Other Psychotic Disorders,” but is this the right place to put it?

Too often, schizoaffective is employed as a glorified NOS diagnosis by clinicians who can’t decide whether their patient has bipolar or schizophrenia. As Goodwin and Jamison and others point out, the current DSM leaves wide room for mutually exclusive interpretations, such as:

A form of bipolar with psychosis, a form of schizophrenia with mood swings, co-occurring schizophrenia and bipolar, a separate illness, or a different phenomenon entirely occupying the psychosis spectrum.

Just to make things more confusing, a patient may appear to have schizophrenia during one phase of his or her life and bipolar in another.

So how would the DSM-5 fix a diagnosis it regards as “unreliable”?

“We recommend the following, minor change in the text ..."

A MINOR textual change? Is that it? Yes, apparently.

Grade: F-minus.

More to come ...

Wednesday, February 24, 2010

My DSM-5 Report Card: Grading Bipolar - Part III

Today’s grading assignment began with an apparently niggly issue that suddenly turned severe. Severity is the topic. Let’s get into it ...

Severity, Mania/Hypomania

The DSM-5 Task Force mandated its various workgroups to come up with sophisticated severity measures analogous to assessing hypertension. This would place far greater emphasis on functional impairment (such as inability to hold down a job) rather than simply ticking off symptoms.

It’s too bad this message got lost in the mail.

Until someone comes up with a foolproof diagnostic test, severity is the only way of separating out mania from hypomania (and thus bipolar I from bipolar II). Indeed, the current DSM already red flags severity (“not severe enough to cause marked impairment”) to distinguish hypomania from mania.

What we need now are some precise measures that would aid clinicians in dialing in the diagnosis, plus perhaps detect the types of subtle “ups” that signal there is more to many depressions than simply depression. A lot of deep thinking is required to come up with the right indicator. Expect, instead, to find a last minute generic patch along the lines of the CGI.

Grade: F-minus.

Severity, General

The workgroup indicated it is considering various standard measures (such as the CGI) for severity for the bipolar diagnosis. One problem is these measures don’t seem to apply to episodes. Thus, for mania, the workgroup notes: “This is not a codeable disorder; therefore, there are no severity criteria proposed.”


Grade: F-minus.

Severity, Cycling

What sets bipolar (including cyclothymia and recurrent depression) apart from other ills is that it is essentially a cycling illness. Thus, “feeling better” may actually be a sign of trouble, of the cycle about to ramp up or change course.

It’s all about the cycle. Fast or slow, extreme or subtle. Without an accurate read, we are literally flying in the dark. Does the workgroup have something in mind? If so, they haven’t told us.

Grade: F-minus.

Severity, Context

Perhaps you are feeling okay now, but you know if you went back to work or had to deal with some troublesome family issues you would fall apart. Is there a severity indicator for that? Consider this assignment extra credit.

No grade.

Severity, Stress

Where there’s smoke there’s fire. A smoke detector would not be difficult to devise. Another extra credit project.

No grade.

The Bipolar Report Card So Far ...

  • Depression: F-minus
  • Euphoric and Dysphoric Mania: F
  • The Mania Minimum Time Limit: D
  • Hypomania as a Marker for Depression: Incomplete
  • Hypomania as a Marker for Mania: F
  • Dysphoric and Euphoric Hypomania: F
  • Antidepressant-Induced Mania/Hypomania: C-minus.
  • Mixed Episodes, Symptoms: C-minus.
  • Mixed Episodes, Spectrum Considerations: C-plus.
  • Bipolar III: D
  • Recurrent Depression: F-minus.
  • Rapid cycling: Incomplete
More to come ...

Tuesday, February 23, 2010

My DSM-5 Report Card: Grading Bipolar - Part II

Part I began issuing grades on the homework handed in nearly two weeks ago by the DSM-5 Task Force concerning its proposed revisions to bipolar. To recap:

Depression - “What were these people thinking? They weren’t.” Grade: F-minus.

Euphoric and Dysphoric Mania - “Is there a secret DSM with accurate information that only a privileged few are allowed access to? And a fantasy DSM for all the rest of us?” Grade: F.

The Mania Minimum Time Limit - “Why seven days? Why not four? Who is truly counting the days when our life is in ruins? Don’t make me answer that.” Grade: D.

Hypomania as a Marker for Depression - “A very strong case can be made for lowering the diagnostic thresholds for hypomania.” Grade: Incomplete.

Hypomania as a Marker for Mania
- “One simple adjustment. Are we asking for too much? Yes, apparently.” Grade: F.
Dysphoric and Euphoric Hypomania - “The same arguments that apply to mania apply here.” Grade: F.

Moving on ...

Antidepressant-Induced Mania/Hypomania

The DSM-5 would recognize that flipping into mania or hypomania as the result of an antidepressant or ECT or other depression treatment  “is sufficient evidence for a manic or a hypomanic episode diagnosis,” but cautions that a mere one or two symptoms (such as irritability) should not be taken as evidence of an episode.

For a change, the DSM-5 Mood Disorders workgroup actually made what would amount to a significant change to the bipolar diagnosis. The catch is they buried it in the usual standard boilerplate which is suddenly not so standard. Trust me, if I failed to pick it up, the person you entrust your life to is not about to pick it up, either.

Grade: C-minus.

Mixed Episodes, Symptoms

In real life there are “pure” depressions and “mixed” depressions, “pure” manias and “mixed” manias. Successfully differentiating one from the other is crucial to treatment success. The current DSM recognizes mixed states only in bipolar I, when depression (with a capital D) and mania (with a capital M) rear their ugly heads together. Thus: DM.

Your best source of finding out what a mixed episode is like is listening to a patient who has been through it. Unbelievably, the DSM never bothered to turn in a description. (Short description: various forms of energized psychic distress, such as road rage, even when not driving.)

In by far the most significant change to the bipolar diagnosis, the DSM-5 would widen mixed states to include two or three mania symptoms (m) inside depression (D) or two or three depression symptoms (d) inside mania/hypomania (M). Thus: Dm or Md.

Presumably, this translates into symptoms strong enough to turn “euphoric” manias “dysphoric” and mind-numbing depressions “agitated.” The problem is the DSM leaves us presuming. Once again, what does a mixed state look like? Do we have to Google the answers, ourselves?

Grade: C-minus.

Mixed Episodes, Spectrum Considerations

The DSM-5 would acknowledge two types of mixed episodes: Predominately depressed and predominately manic/hypomanic, which would include for the first time those with bipolar II. The DSM-5 workgroup is undecided whether to include mixed states as episodes in their own right or as specifiers to depressive and manic episodes.

Inexcusably undecided is the workgroup’s position on mixed states in unipolar depression (see Part I to Grading Depression). Why would mixed depressions somehow be regarded as exclusive to the bipolar diagnosis?

Last but not least, why should a mixed depression or mania/hypomania require a full-blown episode? Think: how well are you truly when you have elements of both depression (d) and mania/hypomania (m) going on at once (dm)? Or, to put it another way, when is counting symptoms a substitute for evaluating functional impairments?

Grade: C-plus.

Bipolar III

Should the threshold for bipolar II be lowered to include patients with so-called “soft” bipolar? These are individuals whose depressions have far more in common with bipolar than unipolar and who do cycle “up,” though not necessarily as high or as long.

Or should a new category by created for them, such as bipolar III?

In other words, why should those who don’t dance on tables be overlooked? Especially if they continue to lead miserable lives treated as if for unipolar depression.

The DSM is considering reducing the time criteria for a hypomanic episode for bipolar II, but is holding the line on the symptom minimum.

Grade: D.

Recurrent Depression

As opposed to chronic depression, recurrent depressions come and go, typically in an up and down pattern. The current DSM includes recurrent depression as part unipolar depression and the DSM-5 would preserve the status quo.

Here’s the issue: If no expanded bipolar II diagnosis or no bipolar III, then why not put recurrent depression into service? Perhaps add new criteria as part of a new “highly recurrent depression” or “cycling depression” diagnosis. There are at least three advantages to this:
  • This would recognize the bipolar nature of these depressions without necessarily acknowledging them as part of the bipolar diagnosis. Clinicians would be encouraged to investigate more closely for these type of depressions before indiscriminately prescribing antidepressants.
  • Since this type of cycling depression would not be regarded as part of the bipolar diagnosis, a clinician need not find evidence of hypomania or mania to make the right call.
  • A cycling depression diagnosis would avoid the stigma of a bipolar diagnosis.
Mind you, for this to happen, the DSM-5 workgroup would have to put the interests of the patient above those who manufacture antidepressants or clinicians too lazy to ask the right questions or insurance companies who refuse to give clinicians time to do their job. I can well imagine the workgroup's deliberations: Explain the concept of patient interest to me ...

Grade: F-minus.


Strangely enough, true rapid-cyclers ride the roller coaster far too fast to be considered DSM-eligible as a rapid-cyclers, much less rate a bipolar diagnosis. Blame the current DSM for this mess, which demands the same “duration criteria” for episodes from everyone (two weeks for depression, one for mania, four days for hypomania).

According to an article in Psychiatric Times, even those responsible for the DSM-IV recognized the absurdity in their thinking. The question remains - can the DSM-5?

Grade: Incomplete.

Much more to come. Stay tuned for Part III ...

Sunday, February 21, 2010

The Draft DSM-5 - Another Blogger Speaks Out

I'll be quick: Blogger comrade-in-arms Willa Goodfellow (pictured here) of Prozac Monologues has written a terrific critique of the Draft DSM-5. Sample:

Particularly disturbing is the failure to include new knowledge about Bipolar II.  The proposed revisions do not even keep pace with practice among psychiatrists who do listen to their patients' experience.  The evidence for a link between antidepressants and suicide is most compelling for those who are diagnosed with Bipolar II or those who could be diagnosed with Bipolar II, if the criteria shifted to include them.  The continued narrow definition leads to inappropriate treatment with antidepressants (translation: more sales of antidepressants), and deterioration, including a tripled risk of suicide

Say no more. Check it out ...

Friday, February 19, 2010

My DSM-5 Report Card: Grading Bipolar - Part I

Last week, the DSM-5 Task Force turned in its homework regarding proposed revisions to the DSM. This week, I started grading its efforts. In my last three pieces, I broke down Team Depression’s term paper and issued the overall grade of F. Can Team Bipolar rise to the challenge?

First, some background:

Before there was bipolar, there was DSM-II manic-depression, which - believe it or not - included a “depressive type” that consisted “exclusively of depressive episodes.”

Bipolar made its official debut as a “mood disorder” in the DSM-III of 1980, with the diagnostic threshold set to full-blown mania. The DSM-IV of 1994 modified its restrictive stance with the inclusion of “bipolar II” and its less stringent “hypomania” threshold. But this failed to satisfy critics, who to this day contend that the DSM-II view of manic-depression was a lot closer to reality.

So, after all these years, are we finally going to witness the unveiling of “bipolar III?”

In the meantime, experts woke up to the fact that bipolar depressions could be very different from unipolar depressions. Plus there was a growing realization that bipolar had more in common with schizophrenia than once thought.

Now that we have set the scene, on with the grading ...


Mania gets all the attention, but depression is what clinicians need to be closely scrutinizing. The DSM calls for evidence of a previous manic or hypomanic episode to diagnose a depressed patient with bipolar, but what if the patient is unable to recall ever feeling good or feeling too good for his or her own good?

The current DSM criteria for a bipolar depressive episode is a straight copy-and-paste from unipolar depressive episode. We now know that patients with bipolar tend to manifest different features to their depressions and react far differently to antidepressants. Some clear red flags in the next DSM would put clinicians on notice.

Gary Sachs MD of Harvard likens depression to the pointer stars of the Big Dipper, offering navigational clues to the North Star that is mania and hypomania. Clinicians would still require evidence of mania or hypomania, but spotting anomalies within depression would help them with their detective work. The DSM-5 workgroup had no shortage of clear pointers to work with. Instead, the workgroup stuck with the copy-and-paste option.

Needless to say, this decision absolutely guarantees that the current unacceptably high rates of misdiagnosis (along the terrible suffering that involves) will continue unabated. What were these people thinking? They weren’t.

Grade: F-minus.

Euphoric and Dysphoric Mania

We tend to think of mania as feeling way too good for our own good. In reality, mania also has a way of manifesting as euphoria’s diametric opposite. These are your road rage states, your crawling out of your skin states. The DSM does acknowledge that mania can involve irritable mood, but this is nowhere near close to delineating night from day.

The DSM also recognizes mixed episodes, which the DSM-5 would widely expand, but even then there is no indication as to what mixed depression-mania actually looks like. Perhaps dysphoric?

All which makes you wonder. Is there a secret DSM with accurate information that only a privileged few are allowed access to? And a fantasy DSM for all the rest of us?

Grade: F.

The Mania Minimum Time Limit

Why seven days? Why not four? Who is truly counting the days when our life is in ruins? Don’t make me answer that.

Grade: D.

Hypomania as a Marker for Depression

Patients typically do not want to be cured of hypomania, but what does frighten them is what is likely to come next, such as crashing into depression. In this context, hypomania is more of a “marker” pointing to pathology rather than a pathology in its own right.

Why this is important is that depressions that cycle in and out (and up and down) are different animals than depressions that don’t. Often they need to be treated differently (such as going with a mood stabilizer rather than an antidepressant).

So, if all we are looking for is evidence of “up,” how high does up need to be? When triangulating depression, not high at all. Thus, a very strong case can be made for lowering the diagnostic thresholds for hypomania (say to two symptoms lasting two days). The DSM-5 says no to the former, but, pending further analysis, may say yes to the latter.

Grade: Incomplete.

Hypomania as a Marker for Mania

What separates hypomania from “normal” behavior is the individual’s own baseline. The operative DSM word is “uncharacteristic.”  Nevertheless, the individual’s functioning is not impaired. Turn up the heat to mania, however, and the picture is far different.

But how do we delineate “normal” (that include ups that are characteristic of a particular individual) from hypomanic from manic? Get it wrong and we will never find the patient’s treatment sweet spot. Needless to say, clinicians get it wrong a good deal of the time. It certainly doesn’t help that the symptom list for both hypomania and mania is exactly the same.

Consider: if the DSM does not regard hypomania as an impairment that interferes with normal functioning, then what is the justification for retaining the following symptom?

Excessive involvement in pleasurable activities that have a high potential for painful consequences ...
(The DSM-5 would remove the modifier, pleasurable.)

As a symptom for mania, however, this could be a key differentiator. One simple adjustment. Are we asking for too much? Yes, apparently.

Grade: F.

Dysphoric and Euphoric Hypomania

The same arguments that apply to mania apply here.

Grade: F.

Much more to come. Stay tuned for Part II ...

Thursday, February 18, 2010

iPhone Photos of the Day - Model Trains

Today I took a mental health break from cranking out DSM-5 blogs and checked out the San Diego Model Railroad Museum in Balboa Park, which has the world's largest indoor display.

Above: Santa Fe station, circa 1950s. For a modern real-life contrast, check out this recent iPhone piece.

Below: Through the forbidding mountain terrain coming out of the Imperial Valley. For an idea of the moonscape east of San Diego, check out these Saturday drive shots.


Wednesday, February 17, 2010

My DSM-5 Report Card: Grading Depression - Part III

This concludes my three-part DSM-5 Depression report card, my answer to the DSM-5 draft proposals issued last week ...


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

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

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

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

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

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

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

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

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

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

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

Grade: F-minus

To Sum Up

Thus concludes my three-part DSM-5 Depression Report Card. Here are the subjects and my grades:
  • Symptom Checklist: F-minus
  • Mixed Anxiety Depression: C
  • Mixed Episodes: Incomplete
  • Chronic and Recurrent Depression: F
  • Severity: Incomplete
  • The Specifiers: F
  • Reactive Depression: F-minus
  • Personality (extra credit): No grade
  • NOS: F-minus
Overall grade: F

Concluding Remarks

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

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

So, what went wrong?

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

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

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

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

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

And Finally ...

I don’t want to come across as negative, but my next Report Card grades bipolar, which will also involve liberal use of the sixth letter of the alphabet. But after that, I will move straight to personality disorders, where I foresee much higher marks.

Coming up: My DSM-5 Bipolar Report Card ...

From the My Report Card series

Tuesday, February 16, 2010

My DSM-5 Report Card: Grading Depression - Part II

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

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

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

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

Moving on ...

Chronic and Recurrent Depression

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

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

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

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

Grade: F.


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

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

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

Grade: Incomplete.

The Specifiers

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

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

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

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

Grade: F.

Reactive Depression

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

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

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

Grade: F-minus.


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

No grade.

We’re not finished. Stay tuned for Part III ...

My DSM-5 Report Card: Grading Depression - Part I

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

First, some background ...

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

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

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

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

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

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

Time to start grading ...

The symptom checklist

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

Critics have identified a number of major problems with the list, namely:
  • It is biased toward identifying depression in women rather than men (such as “appears tearful”).
  • It fails to identify the patient’s predominant state of mind. For instance, it is possible to check off “feeling depressed,” followed by “significant weight loss,” “insomnia,” “psychomotor agitation,” and “fatigue.” Voila! Major depression, but what does that tell us? Is one vague mental symptom followed by four physical ones truly depression?
  • It fails to identify the patient’s predominant state of mind (again). Sad? Agitated? Unmotivated? Feeling hopeless? Overthinking things? Excruciating psychic pain? Yes, we know it’s depression. But what is really going on?
On the other hand, the list has been in service for 30 years. It may not be perfect, but it does give us a reasonable approximation of a condition that so profoundly lays waste to so many. So why change it? This was the approach adopted by the workgroup.

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

Grade: F-minus.
Mixed Anxiety Depression

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

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

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

Grade: C.

Mixed Episodes

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

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

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

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

Grade: Incomplete.

We’re not finished. Stay tuned for Part II of the Depression Report Card ...

Monday, February 15, 2010

My Draft DSM-5 Report Card: Hint - Don't Expect Liberal Use of the First Letter of the Alphabet

My previous two pieces on the draft DSM-5 hinted that we should rip it up and start over. Okay, okay, it said so right in the title - Part I and Part II - but I didn’t think people actually read those things. Now that you know where I stand, in future blog pieces I’m going to start issuing DSM-5 report cards, complete with passing and failing grades.

I will start by breaking down the DSM-5 draft proposals for depression, then in later pieces move on to bipolar and the other mood disorders. Then over to schizophrenia and psychosis, anxiety, ADHD, the personality disorders, and on and on down the line until I run out of material or run out of steam, whichever comes first.

But before I do, my disclosures:

I am living with a mental illness. My diagnosis is bipolar I mixed, which is a fairly accurate reflection of my condition, as it’s one of the few areas of mood disorders that the current and previous editions of the DSM actually got right.

I mean, seriously, how could they not get it right? You should see me when I go crazy. You don’t need a panel of experts to determine my condition. The cast of Jersey Shore sleeping off a group hangover could make the right diagnostic call, as could Paris Hilton contemplating a broken finger nail

And in case people might mistake a crazy raving maniac (me) for a crazy raving individual with schizophrenia, it just so happens that I deliver my raging insults in four-syllable words arranged in perfect ironic sequences, with precision Pythonesque timing.

I’m not through. Very rarely do I get manic. Depression has been the bane of my life, so naturally when I first sought help, the psychiatrist who evaluated me wound up diagnosing me with unipolar depression and prescribing an antidepressant. This had me bouncing off the walls and ceiling, which, of all things, brought me out of my suicidal depression in a hurry and probably wound up saving my life.

But still, the shrink had no way of differentiating unipolar depression from bipolar depression? See what I mean about disclosure, here? This is my friggin’ life on the line. My life! Talk about personal bias.

Anyway, here I am conducting my own failure analysis: If it’s unipolar depression, the antidepressant has a good chance of getting me better. If it’s bipolar depression, my ass is grass on an antidepressant. This isn’t like a waiter getting my order wrong and bringing me the chimichanga instead of the carne asada platter. This is major.

Yet a doctor of medicine specializing in psychiatry screwed up. Amazingly, I discovered, this was no fluke. Psychiatrists do this all the time. So, either psychiatrists are doctors not smart enough to be proctologists or there was a major system failure that could be laid at the two left feet of the DSM-IV.

Moving on, I have lots of other crap going on. In certain situations, I freeze like a deer in the headlights. In others, I would swear my thoughts were coming from outside my brain (or, at least, my neurons weren’t taking any of the credit). Other times, in social settings, it’s either as if I’m invisible or as if everyone else is backing slowly toward the exits.

There’s no DSM disorder for this type of stuff, or if there is I have yet to find it. The best I can come up with is I experience a “little bit of this” and a “little bit of that.” As in a little bit of anxiety and panic, a little bit of attention deficit disorder, and a little bit of a whole shit load of personality quirks.

Granted, by reading up on the full-blown versions of these DSM conditions I am able to acquire an insight into why my brain operates like a precision Swiss watch with a few jewels missing, but it would be nice if the people I entrust my life to had this appreciation, as well.

Namely, it’s not enough for me to get my official DSM-IV bipolar under control. If I want the kind of life that most others take for granted, I have to learn to manage my other weird shit, as well. And maybe if psychiatry had a system for triangulating all these various symptoms across the diagnostic categories then maybe we could really find out what is going on in our brains and actually do something about it.

So you see, compared to the academic researchers working on the DSM-5, I have competing personal interests all over the place. By contrast, the DSM-5 people have only minor concerns such as past ties to the drug industry and their various convoluted reasons for wanting to keep things the same forever.

Past industry ties, it turns out, are a much bigger problem than I would have thought. The illnesses in which meds are typically the backbone of treatment (such as mood disorders) coincide with the sections of the DSM involving the fewest proposed changes. By contrast, the areas of the DSM where Pharma is invisible (such as personality disorders) involve by far the most sweeping changes.

This pattern also coincides with who rules the roost in academia and who are seen as the poor relations. This bears much closer scrutiny in future pieces.

But by far the most disturbing factor about competing interests is that those working on the DSM-5 didn’t evidence even remotely similar ones to mine. Otherwise, they might have cared about the homework they turned in.

As you can see, my first grade is not about to be an “A” for effort.

Sunday, February 14, 2010

The Draft DSM-5 - Rip It Up and Start Over: Part II

Allow me to explain the title to this piece and to a recent piece:

“Creative destruction” is a term popularized by Joseph Schumpeter in the 1940s to explain the necessary and typically heart-breaking disruption and chaos that gives rise to economic progress. Think changing times. The advent of the automobile put buggy whip manufacturers out of business. In turn, the likes of GM grew at the expense of smaller auto manufacturers. And the process continues today with GM fighting for its life in a new global economy.

It’s a never-ending cosmic dance of destruction and creation, exemplified by the Hindu diety Shiva.

A post-GM world, followers of Schumpeter would argue, promises to be a better one: Imagine a leaner and greener auto industry responsive to consumer needs and environmental realities. Yes, the transition is bound to be devastating, but indiscriminately trying to soften the pain, they would say, only leads to stagnation and decline.

In the field of psychiatry, the exemplar of creative destruction was Robert Spitzer, who boldly took on the cult of Freud and ushered in a new era of psychiatry. The ground-breaking DSM-III of 1980 and its follow-up DSM-III-R of 1987 were his great achievements. Thanks to Spitzer and his contemporaries, we seek out psychiatrists and therapists to treat our depression rather than undergo analysis to root out our neurosis.

Ironically, though, the unprecedented success of Spitzer's DSM spawned its own problems. Suddenly, we had “stakeholders” in the form of the insurance industry, the drug industry, the research establishment, not to mention psychiatry and its related professions. Oh, yes, patients too, but who listens to us?

Overnight, the DSM became entrenched, incapable of correcting even its most obvious faults, incapable of folding in new insight. Take the current DSM’s view of depression - please! - which is virtually unchanged since the DSM-III. Yes, the DSM-III version is an improvement on the DSM-II of 1968, but at least the older view recognized the complexity of the condition and its context, namely:

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

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

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

Viewing depression as a single and non-complex entity offers the advantage of clarity in a world where clinicians and other interested parties need to be speaking the same language. The problem occurs when this simplistic view encourages equally simplistic treatments.

(Yes, the current DSM distinguishes the likes of melancholic from atypical depression and makes room for depression with psychosis and the like, but only if the full criteria is met for a depressive episode.)

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

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

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

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

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

In other words, never mind what is convenient to the industry-professional-research establishment. To move forward, first we need to journey back to the naive and confusing DSM-II and acknowledge that the real world of depression is highly nuanced and complex. Then, maybe we could deploy our modern knowledge to develop a new and sophisticated, but no less confusing, understanding.

Instead, the DSM-5 Mood Disorders Work Group in a report from April 2009 signaled it was using the DSM-III (upon which the DSM-IV is based) as its starting point, noting that a subgroup was reviewing “whether there is sufficient data to support adding or removing symptoms” to or from the major depression checklist.

Often, the results justify working off an existing document. But no changes? With no explanation? After all we have learned since 1980? With our lives at stake?

A little creative destruction, please. Time to rip the thing up and start over.

Much more on the DSM-5 draft to come ...

Friday, February 12, 2010

iPhone Photo of the Day - Baby Llama

It's a zoo where I live. So, for a change of pace I check out the neighborhood animals.

Thursday, February 11, 2010

The Draft DSM-5 - Rip It Up and Start Over: Part I

Yesterday, the American Psychiatric Association’s DSM-5 Task Force released its much-anticipated draft to the next DSM, scheduled for completion in 2013. The document is available for viewing and comment on the APA’s website.

Where to start? Let’s go with my diagnosis - bipolar - as well as the bane of my life, depression. First some background:

Written observations on depression and mania go back to ancient times. How could Plato, for instance NOT notice Socrates acting weird? But observations do not equate to understanding, and, crazy as it sounds, what was beyond the grasp of ancients continues to elude today’s experts, namely:

How do depression and mania relate? Part of the same phenomenon? Or separate? A bit of both?

How do depression and mania fit into the human condition? Natural temperament? Or outside force that takes over the mind? A bit of both?

By the last half of the nineteen century, medical science had connected depression to mania. “Folie circulaire,” the French called it. In the early twentieth century, the pioneering German diagnostician, Emil Kraepelin (pictured here), coined the term manic-depression. But here’s the rub - manic-depression to Kraepelin and generations to follow was not synonymous with what we now call bipolar. Manic-depression also embraced what we now call unipolar depression.

Kraepelin saw depression as a “recurring” phenomenon. Some individuals cycled up into raving mania, then back down into depression (often with long periods of remission). Others simply cycled up into milder states.

In essence, Kraepelin saw depression and mania as occupying opposite ends of the same spectrum, different but closely related, with the same underlying cyclic features. Kraepelin also viewed manic-depression as a biological illness, but nevertheless occupying a spectrum that embraced the temperaments that influence our personality.

Kraepelin’s model proved to be a bit too overreaching. In the 1960s, Jules Angst and others identified “chronic” depression and parsed it out from “recurrent” depression. But the Kraepelin model still held. During the 1970s, Frederick Goodwin and others regarded recurrent depression as a close cousin to bipolar rather than a sibling of chronic depression.

This bears repeating: The leading investigators of the day viewed manic-depression as embracing both bipolar and recurrent depression. Chronic depression was seen as a separate phenomenon.

Another way of viewing the spectrum, pioneered by Angst, is by conceptualizing “pure” mania at one end and pure depression at the other, with a lot of mixing it up in the middle. Thus, severe depression with a bit of mania might look like this - Dm - while hypomania with some depression would be represented as - md. And so on. Under this view, “mixed” states (think agitated depression or dysphoric mania) are seen as closer to the rule rather than the exception.

Meanwhile, we had Freud to consider. Freud’s followers saw depression and mania (and other states) as not necessarily biological, but as maladaptive reactions to one’s environment. Freud was the dominant mindset of psychiatry when the APA published the DSM-I in 1952, replete with its inclusion of “manic-depressive reaction.”

Oddly enough, “manic-depressive reaction” embraced Kraepelin’s wide view of the illness, but as an outward expression of underlying psychosis. Since Freudian psychiatrists wrote off those they saw as “psychotic” as hopeless and uncooperative, there was little interest in working with these patients. Their fate was institutional neglect.

“Neurosis” and “behavior” by contrast, defined psychiatry’s walking wounded as well as its meal ticket. The DSM-I made provision for both depression, and manic-depression lite (cyclothymia) as either a manifestation of anxiety-driven neurosis or as embedded in one’s personality. This accorded with the Freudian mindset of rooting out the underlying neurosis or behavioral quirk rather than helping patients manage symptoms. Hence there was little professional interest in depression and other ills as entities unto themselves. Hence, there was little interest in the DSM.

The DSM-II of 1968, largely a rerun of 1952, met with the same underwhelming response. But change was in the air. First-generation psychiatric meds, coupled with the realization that not many patients actually got better under Freudian therapy, give rise to a new era of diagnostic psychiatry, with Kraepelin as its inspiration. Leading the charge was Robert Spitzer, with a modest brief to tweak the DSM so it harmonized with international standards.

Spitzer had other ideas. With a strong supporting cast of psychiatric researchers who valued science over dogma, Spitzer set about producing a document that would allow professionals worldwide to communicate in the same language. A major innovation was the “symptom list” that represented a giant leap forward from Freud and his neurotic muck.

What was widely understood by those working on what was to become the DSM-III of 1980 was that their efforts would represent a work-in-progress. With psychiatric science in its infancy, it was a given that new data and new insights would supplant the best guesses that Spitzer and his team were coming up with. Mistakes were inevitable, but you had to start somewhere. Just so long as you could correct them later.

Just so long as you didn’t cement yourself into a corner for the next 30 years.

Next: The DSM cements itself into a corner for the next 30 years ...

Further reading:

Wednesday, February 10, 2010

The Draft DSM-V - Few Surprises

This just in: The American Psychiatric Association’s DSM-V Task Force has just published a rough draft of its proposed changes to the DSM, psychiatry’s diagnostic bible. The document is available for viewing and comment on the APA’s website.

The new version of the DSM, scheduled for publication in 2013, would supersede the current DSM-IV, in effect since 1994. (There is the DSM-IV-TR of 2000, which involved only minor technical adjustments.) The DSM-IV - and before that the DSM-III-R of 1987 - represented incremental changes to the groundbreaking DSM-III of 1980. The proposals for the DSM-V would go a lot farther, but can hardly be regarded as revolutionary.

Essentially, the new DSM would build on our current system of classifying mental illness according to clusters of symptoms rather than underlying causes. In essence, the people who did the original legwork on depression, bipolar, anxiety, schizophrenia, and the like got a lot of it right on the first go. On the other hand, the brain science that promises to turn all our current assumptions upside-down is not there yet.

Thus, the DSM-V will be a conservative document. The DSM-VI, assuming the DSM is still around in say 2025, will be a whole new ball game.

Following are some quick impressions:

Personality disorders. Only in the field of personality disorders did the DSM-V Task Force essentially rip everything up and start all over. The Task Force had telegraphed its punches in earlier discussion papers, noting the extreme confusion and overlap that exists in the current DSM.

What we will see is a “hybrid” system that preserves the old “categorical” approach but introduces a “dimensional” perspective. Thus, “borderline personality disorder” will survive as “borderline type” (and be included with other “types”), but clinicians will also be able to make alternative diagnoses based on personality “levels” (involving “self” and “interpersonal”) and “trait domains” (such as “emotional negativity”).

Mood disorders. Same-old, same-old. The symptom lists for depressive and manic episodes remain intact. So do the bounds of bipolar (no bipolar III or IV to add to bipolar II). What’s new is a widened definition to “mixed” episodes to embrace both depression and bipolar II (rather than the current version which only applies to bipolar I); mixed anxiety depression; a widened definition of dysthymia to emphasize its chronic nature and to include major depression, presumably to differentiate chronic from recurrent depression.

Schizophrenia and psychosis. Some retooling of the definition of schizophrenia, elimination of the various categories of schizophrenia, no new definition of schizoaffective. What’s new is “psychosis risk syndrome,” which would encourage clinicians to seek out tell-tale signs and engage in early treatment, before it is too late.

Anxiety. Major change: OCD be included in another category of disorders.


There is a lot more to the DSM-V proposals than I outlined here. This is just a quick first pass. A lot more to come, lots more ...

Further reading

Last October, I did a five-part series on the development of the ground-breaking DSM-III of 1980 and the issues involved, plus my unexpected dinner with its prime mover, Robert Spitzer:

Another Police Shooting in Fairfax

Here we go again. Saturday’s Washington Post reports:

A Fairfax County officer shot a Herndon area man inside his home early Friday after he brandished a pistol at police, and his wounds were life-threatening, authorities said. The 25-year-old man was thought by neighbors to be mentally ill, and police said they had obtained an emergency custody order for him, which is typically used for mentally ill people in need of treatment.

My two previous blog pieces focused on the death of David Masters, gunned down in his vehicle by Fairfax County police in November. In late January, the prosecutor, citing David’s history of mental illness, announced his office would not be charging the police officer who fired the two shots.

A Facebook group page, Praying for Ian Smith, reports that Ian - the man shot in his home - has had three surgeries and will be undergoing a fourth. He was initially given little chance of survival and his situation remains critical. According to family member Hayley Smith posting on the page:

The only problem with the story is Ian did NOT in fact have a pistol. they claimed he was holding a weapon which they later found out was just a BB gun.

An empty BB gun, she noted in a follow-up post.

It seems conflicting accounts between the police and the public are not all that rare. I had my eyes opened to this two or three years ago, when at a psychiatric conference I happened to run into someone I had met in the course of my advocacy work when I lived in New Jersey.

We got talking and decided to grab a sandwich. Then he told me an amazing story. To protect his privacy, I’m going to obscure the facts concerning his identity:

“Jim” had just graduated with an advanced degree in a prestigious and lucrative field. He was looking forward to the beginning of what promised to be a long and rewarding career. Then, celebrating at his parents’ house, something crazy happened - he went crazy. He had a psychotic episode. He picked up a knife.

His parents, alarmed, called the police. Officers entered the house. A confrontation occurred. From the other end of the room, an officer shot Jim through the neck, narrowly missing an artery.

Jim pointed to the scar tissue on his neck. Many years after the incident, he is still struggling to get his life back. Had I not been rendered so speechless by Jim’s account, I might have asked some decent follow-up questions, the kind that are supposed to come naturally to journalists such as myself. Instead, I found myself flailing, grasping for words.

At last I recalled an article I had come across in the New York Times years back. The story concerned a young man, Gidone Busch, raving delusionally with hammer in hand, fatally gunned down by police. According to the police account, the man had been attacking one of the officers.

Jim laughed ruefully. The police version, he said. He wasn’t buying it. Not after what had happened to him. According to the police version, he had attacked the officer with a knife. Then, as he lay unconscious on the floor with his life bleeding out of him, the police moved the knife to make their story convincing.

I nodded knowingly. Who are you going to believe? The police or some nutjob wielding a deadly weapon? Especially if the nutjob, due to such issues as being dead, is unable to relate his side of the story.

Okay, some context:

In nearly all stories fellow patients have related to me, the police acted professionally. They were compassionate. They were diplomatic. They knew how to handle a tricky situation. And, instead of booking the individual, they admitted that person to a psychiatric facility.

A lot of the credit goes to Major Sam Cochran of the Memphis Police. Back in 1988, in the wake of highly publicized shootings involving individuals with mental illness, Mr Cochran drew the assignment of doing something about the situation. His department teamed up with NAMI and the University of Memphis and the University of Tennessee, pulled in other organizations and professionals, and together they organized a special unit called the Crisis Intervention Team (CIT).

As well as performing their standard police duties, these specially-trained officers respond to situations relating to mental illness. The police have always been first-responders to situations regarding the mentally ill, but their standard training often sets them up to fail.

A dramatic turn-around occurred soon after enough officers were trained and CIT became standard operating procedure in Memphis. Injuries went down, both for the mentally ill and police officers. So did arrests. So did complaints against the police. The police helped steer untreated individuals to psychiatric services. What was to become known as “The Memphis Model” was implemented in police departments nationwide.

At two different NAMI conferences, I went out of my way to introduce myself to Mr Cochran, shake his hand, and express my gratitude for making my world a much safer place. But in most departments, CIT is still a luxury, and in this economic climate a low priority. In 2008, the Fairfax police trained some officers in CIT, then stopped.

Now, one man is dead and another is in an uphill battle for his life. Words fail me ...

Monday, February 8, 2010

Police Relations and Personal Safety

Yesterday, I summarized a Washington Post op-ed piece by author Pete Earley (“Crazy: A Father’s Search Through America’s Mental Health Madness”) that was harshly critical of a Fairfax County (VA) prosecutor’s reasoning in deciding not to charge an officer for fatally shooting an unarmed man in his vehicle.

The prosecutor, in a public statement, rationalized that because the victim, David Masters, had been diagnosed with a mental illness and had been reported by his family as acting strangely earlier, then, apparently, it was okay for the officer to fire two rounds into him.

David Masters, a former Green Beret, had been suspected of stealing flowers outside a shop. Fairfax County had provided some police with Crisis Intervention Training (CIT) in 2008, but it hasn’t been offered since. CIT teaches police how to respond to situations involving individuals with mental illness.

I was not planning to do a follow-up. But that was before I read the comments to Pete’s op-ed.

“This article is a load of crap,” read one. “The cop did what he did based on this training. JOIN THE DEPARTMENT IF YOU HAVE THE STONES TO DO SO INSTEAD OF BITCHING HERE!!!”

Read another: “Monday Morning QBs. I'm pretty sure you'd all place blame on the officer if he were shot and killed.”

And another:

You should do a ride-along with your local Police Dept and learn just how dangerous it is to be a cop when stopping someone. It is really quite enlightening - much more so then watching "cops" on tv. would help of citizens were better trained on how to behave properly when interacting police officers: keep your hands where they can see them and then tell them what you are going to reach for and when you are going to reach for it. No surprises for them means no surprises for the citizen.

Fortunately, the expressions of outrage far outnumbered those who would issue every officer with a license to kill:

“Since when is bizarre behavior an excuse for the police to shoot someone?” is fairly representative, as is:

A cop's primary responsibility is to protect the community that pays him to serve it, which at a minimum means not shooting people if you don't have to. If his primary responsibility was to protect himself, he would shoot everything that moves.

Before I get to my response, here is a doozy that was posted several minutes after mine:

Oh so easy to second guess at a computer screen in a nice office rather than face crucial decisions on the street. Let's have more concern for citizens on the highway and others (including the police) put in danger from a deranged person or who suffer financial and other loss because of that person. (And if you want to say "it's only money" then you cover any damages from your checkbook) If there is a "villain" in this piece it is the system that allows deranged, volatile people--mentally ill--people to wander at will. Sorry, my sympathy in this case in limited. If you disagree invite the crazies--yes, politically incorrect as it may be to call them that--to your neighborhood and street.

Finally, my response:

The commenters defending the prosecutor and police here expressly state that the author and those who agree with him have no understanding of the police and the dangers they face. That is blatantly untrue. If understanding is the issue, I would cordially invite these same individuals to learn about mental illness. It's everywhere and it's very close to you if you open your eyes to it. Moreover, no one is immune from it - not even "normal" people.

Public safety is a major issue, but heaven help your personal safety if you just happen to panic behind the wheel of a vehicle and you fail to control your fear and agitation. A uniformed man with a gun is approaching. You've lost your ability to stay calm or even follow simple instructions. In that situation, you better pray to God that the officer has had CIT training. You better pray to God that officials who represent you and your fellow citizens hold that officer accountable for his actions. You better pray to God that the public - which includes your friends and family and neighbors and colleagues - understands you. Otherwise, you - yes you, Mr Normal - are just a nutjob who pissed off a cop. Are you ready to live in that kind of world?

No doubt this won’t be my last post on the issue. Stay tuned ...

Sunday, February 7, 2010

Pete Earley - Outrage in Fairfax

Pete Earley is the author of the highly-acclaimed “Crazy: A Father’s Search Through America’s Mental Health Madness.” Prior to turning his attention to mental illness, Pete, a former Washington Post investigative journalist, had achieved fame writing books on such topics as crime, criminal justice, Vegas, and spies. Then, one day, out of nowhere, ten tons of bricks dropped on his head.

Several years ago, Pete stood by helpless as his son Mike, fresh out of college, went off his Zyprexa and flipped into florid psychosis. But for doctors to treat him, first they needed his consent. Never mind that Mike’s condition had robbed his brain of all power to reason. Rules are rules. Of course, should Pete's son do something outrageous ...

A couple of days later, Mike obliged. In a highly delusional state, he broke into someone’s home and took a bubble bath. It took six Fairfax County (VA) police and a police dog to subdue him. Now a felony charge hung over Pete’s son. As Pete explained to a session I attended at the 2006 NAMI convention: “We’ve made them criminals as well as mentally ill.”

Pete’s wife urged him to do as a journalist what he could not do as a parent. Driven by his family nightmare, Pete did his own homework and turned in an eye-opening account of the degradation and horror visited upon those left to fend for themselves.

I’ve had occasion to meet up with Pete twice since then. (Pete was highly complimentary of my own book, and provided me, unsolicited, with a ringing endorsement.) He’s in high demand as a speaker at mental health conferences, and when he talks he leaves no doubt that the fire burns hot in his belly. Same with when he writes.

Yesterday’s Washington Post features an op-ed piece by Pete. According to the facts he presents:

In November, David Masters, 52, was fatally shot in his vehicle at a busy intersection after being stopped by police, who suspected him of stealing flowers outside a local business. On Jan 27, Fairfax Commonwealth’s Attorney Raymond Morrogh announced that his office would not file charges against the unnamed police officer involved in the shooting.

In Pete Earley’s words, Morrogh ...

... offered this stunning summary of what happened: "Unfortunately, we had a mentally ill man who was behaving bizarrely ... His family indicated he was behaving under delusions, that he might feel he was under attack if approached by the police. I think that's the explanation for his actions."

Pete is quick to point out that this is pure speculation on the part of the prosecutor, who apparently felt that an after-the-fact determination that Masters must have been crazy was reason enough to fire two rounds into him. As Pete points out:

The three officers did not know that Masters had been diagnosed with bipolar disorder when they confronted him. Many drivers open their jackets to retrieve their wallets when stopped by the police. The fact that a driver might be belligerent or challenge the police when confronted is not some automatic signal that he is mentally ill. What proof does Morrogh have that Masters was in the midst of a psychotic or delusional episode when he was stopped?

Pete also notes that “Morrogh's statement implies that individuals with mental illnesses cannot control their disorders and are prone to violence,” and that “even if Masters's disorder actually was a factor, there is an excellent chance that the officers who confronted him were not trained in how to determine whether someone acting ‘bizarrely’ is psychotic.”

Pete goes on to say that Crisis Intervention Training (CIT), which teaches police how to respond to situations involving individuals with mental illness, was offered to Fairfax Police in 2008, but has not been offered since.

Why are we not surprised?

(Note: Lest we rush to judgment, there is nothing in Pete's piece to suggest that the officer involved should be charged in the fatal shooting. That is obviously a separate issue. The concern here is the prosecutor's outrageous disregard for a citizen his office is charged with serving and protecting.)

Friday, February 5, 2010

Tom Wootton - Visionary off the Edge

In three previous blog posts I created the impression that my friend Tom Wootton’s new book, Bipolar in Order, is a prime example why American civilization is in decline, which is true. I also made it clear that Tom is a visionary who got us thinking that we could lead better lives than the poor unfortunate souls operating within the “normal” emotional bandwidth.

In his 2007 book, The Depression Advantage, Tom represents himself as a person with “over 40 years of direct personal experience with bipolar symptoms” who, during one 15-year stretch “fluctuated between increasingly more extreme mania and depressions.”

But in January 2009, I played a video of a presentation he gave, in which Tom disclosed that, as well as manias and depressions, he had also experienced schizophrenia.

Schizophrenia? I got my first taste of trouble during this time when I asked Tom to write a guest blog for me. He suggested the preface to the new book he was working on. Fine, I said, so long as the preface works as a blog piece. Often they don’t. His draft repeated his assertion that he had experienced schizophrenia. I said he needed to delete the schizophrenia reference and replace it with psychosis.

Here is the email in full he sent back to me: “What is the difference between schizophrenia and psychosis?”

Suffice to say, our guest blog project never got off the ground.

Tom, in his new book, retreats from his claim of having experienced schizophrenia, instead referring to his delusions and hallucinations as “bipolar I schizoaffective.” Even the experts are confused about the schizoaffective diagnosis, but it’s safe to say that there is an overlap between bipolar and schizophrenia and that many individuals experience symptoms of both.

Nevertheless, in his book, Tom claims expertise in helping others gain control over the psychosis in schizophrenia, but he cites no case studies. His one and only example is John Nash in the movie version of “A Beautiful Mind.” John Nash is a real individual, but the movie treatment, especially in relation to his psychotic delusions, is fictional.

“In the beginning of the movie,” Tom writes, “his hallucinations helped him to see solutions to his mathematical problems. This ability earned him a Nobel Prize.” Imagine, Tom asks, if John Nash had been able to harness those abilities.

Sylvia Nasar’s book of the same name, upon which the movie is based, paints an entirely different picture, revealing an early John Nash as high functioning, though clearly a social oddball. The mathematical breakthroughs that led to his Nobel Prize occurred BEFORE his schizophrenia broke out. Once the delusions set in, by Nash’s own admission, he lost 25 years of his life to the illness.

Ms Nasar’s narrative suggests that Dr Nash may have been straddling a dangerous fault line where genius borders madness, but that is an entirely different discussion.

Since Tom gives workshops, it is reasonable to assume that he would have been anxious to document people he worked with, people he rescued from the hells of schizophrenia who went on to lead full lives. I would have loved to have read about this. Instead, all we get is a fictional example.

A fictional example.

This sort of thing goes over well in public speaking, where a skilled presenter can manipulate crowd emotions. At the NAMI CA conference last year, Tom actually drew applause from his fictional use of John Nash. But the left-brain world of the printed word demands substantial non-fiction documentation.

A personal example then? At both the conference and in his book, Tom describes experiencing the sensation of being crushed by a bus and finding himself inside his wife. Tom tells us this delusion is part of a pattern of similar ones that visit him. But instead of being freaked out, Tom tells us, or trying to put these delusions out of his mind, he incorporates these experiences as part of his own personal growth.

Had Tom restricted himself to his own experiences and built on them, he would have found many people who would have related. I, for one, have a creative and very quirky mind. Weird shit runs through it. And, like Tom, I too find myself contemplating my weird shit rather than ignoring it.

To be crushed by a bus. To be dead and in someone else’s body. Had this experience happened to me, automatically I’d be asking myself stuff like: What was it like to be dead? Is dead overrated? When is going into dead mode helpful to me?

Trust me, Stephen King turned this kind of thinking into a career. Tom is using it to seek greater insight and spiritual growth. Tom’s point is that it is not the psychosis that is bad - it’s how you react to the psychosis. Oddly enough, this is vintage Freud. The pre-brain science era DSM I of 1952 views mental illness as maladaptive reactions to one’s environment, including “schizophrenic reaction.”

There is some validity to rehabilitating this viewpoint, and the time is ripe for a full and spirited conversation. To a certain point, we all have the power to choose. But the kind of fleeting psychosis Tom experiences - or for that matter my own weird shit - is not schizophrenia, nor, for that matter, heavy duty psychosis. Being robbed of all power to reason is a whole different phenomenon.

There is a dangerous tendency to romanticize and trivialize schizophrenia, then morally judge those who fail to live up to our own often unrealistic expectations. Tom’s book is rife with this. Clearly, he has yet to spend a day negotiating rounds of transactions in public places dragging around someone with raving psychosis. Until he does, Tom needs to stick to his own experiences.

Reality is a treacherous place, where ivory tower ideas tend to founder. Tom compares himself to Columbus finding a new world. After reading Bipolar in Order, I see him more as a blind visionary who sailed off the edge.

This series of blog pieces sets the scene for future conversations. Stay tuned ...

Thursday, February 4, 2010

Tom Wootton - A Visionary Overreaches

In two of my most recent blog posts - Bipolar in Flux and Visionary or Out of Touch - I made it clear that my friend Tom Wootton’s just-released “Bipolar in Order” is the worst piece of crap ever assembled between two covers. Besides the book being extremely badly-written and a blatant advertisement for his workshops, the author displays a complete ignorance of an illness he claims an affinity to.

But my first two pieces were actually highly-complimentary, focusing on Tom as a visionary who got us thinking that our manias and depressions, with mental discipline, could be turned to our advantage.

“Normal” people don’t have a chance against us, once we get our disorder “in order.”

Love him or hate him, you really have to admire Tom for putting that thought out there. Tom is by far the best public speaker I’ve ever come across in the field of mental health, and early last year I decided to view the master at work by checking out some videos of his talk segments. Here is what he said in his intro:

Some of you are going to think I’m crazy, which is true. I’ve got bipolar I, extreme manias, totally out of control, extreme depressions, and schizophrenia ...

Schizophrenia? My brain initially didn’t process the statement. It was only a day or two later that something went off in my head: “Did Tom actually say he had schizophrenia?” No, I thought. My mind is playing tricks on me. I actually went back and replayed the thing.

Yep, Tom actually said he had schizophrenia.

When we first met in the summer of 2006, Tom had been representing himself as someone with bipolar. His book from that year, "The Bipolar Advantage," focused exclusively on mania, with a work-in-progress on depression.

In the video I viewed, Tom referred to his own delusions and psychosis and paranoia, which I have no reason to doubt. After all, many depressions and manias come preloaded with these symptoms. But schizophrenia? There is a lot more to schizophrenia than psychosis and delusions and paranoia. Psychosis gets all the attention, but a major reason antipsychotic medications are not a magic bullet for schizophrenia is they fail to address the many cognitive dysfunctions associated with the illness, as well as the “flat affect” features.

Moreover, the DSM mandates a minimum time requirement of six months. This threshold is totally arbitrary. What is important is that the experts view schizophrenia as a long-term “chronic” illness, as opposed to the “episodic” nature of mood disorders. In other words, hallucinations and other psychotic features that occasionally come and go do not rate as schizophrenia, which is a good thing as otherwise four percent of the population would be walking around with a schizophrenia label instead of just one percent.

But if Tom truly had schizophrenia, why didn’t this come out in “The Bipolar Advantage,” which was largely autobiographical? Why didn’t this come out in the numerous conversations I had with him? More important, why didn’t it come out in a workshop I saw him present in Orange County in late 2006?

I had just moved to southern California. Tom was giving the talk under the auspices of a county mental health agency and here was the catch: He couldn’t just talk about the depression and bipolar advantage. It had to be something like the mental illness advantage. His talk had to include everyone.

The organizer of the workshop proved extremely efficient in busing in a large audience comprising those using county mental health services. This was not your typical DBSA segment that Tom was used to addressing, people with an “invisible” illness who do not stand out from a crowd. Far from it.

A number of individuals wheeled in grocery carts with their possessions. A good many looked lost and disoriented, some with thousand-mile stares in their eyes. The dress code was highly eclectic, featuring thrift shop specials, often randomly arranged. No doubt, individuals with depression and bipolar were well-represented, but it was clear Tom was addressing a large number with schizophrenia.

“Hey, I’m no different than you,” Tom could have told this group of people. He could have disclosed his struggles with schizophrenia and had everyone eating out of his hand. Instead, it was clear that there was a separation between speaker and audience. Tom gave a masterful presentation, of course, but afterward he admitted to me it was the toughest audience he had ever faced.

Naturally, I concurred. After all, what could he possibly know about schizophrenia? It turns out absolutely nothing.

More to come ...