Brain Science and Recovery - Knowledge is Necessity

My last two pieces - on psychiatrists behaving badly - diverted me from my true mission here at Knowledge is Necessity, namely providing food for thought in the quest of knowing thyself. A very key part of that is passing along any cool brain science stuff I happen to pick up along the way.

Brain science and ancient wisdom represent the crucial double helix in our getting well and staying well. After decades of guess-work psychiatry, researchers have finally figured out how to open up the hood and peer into the brain’s moving parts, and what they are finding out can be applied by us right now in our recovery. I have been shouting this from the roof tops for nearly ten years, and I have no intention of stopping.

My starting point this time is Barbara Oakley’s must-read 2007 “Evil Genes: Why Rome Fell, Hitler Rose, Enron Failed and My Sister Stole My Mother's Boyfriend.” Last week, in Figuring Out Human Behavior, I couldn’t hide my enthusiasm for Dr Oakley’s show-and-tell of the brain science, which paralleled a lot of my research and writing. For both of us, the focus was the serotonin transporter gene, perhaps the most-studied gene related to psychiatric disorders.

To recap: A glitch in this gene predisposes certain people to over-react to environmental stressors, which in turn makes them sitting ducks for depression and other conditions. The breakthrough work came out in the early 2000s, and makes an excellent teaching lesson for a number of points we all need to know, namely:

• Our genes and our environment interact. We may not have any choice in changing our genes, but we can often choose to change our environments in a way that lets sleeping genes lie.
• Genes are not deterministic, but they do predispose us to how we react to whatever life may throw our way.
• Stress is the key driving force in mental illness. There are other factors, but stress is invariably complicit. A good deal of mental illness can be summed up as “stress vulnerability disease.”
• Diagnostic categories useful to a point, but malfunctions in serotonin transport have been linked to anxiety, mania, depression, substance abuse, borderline personality disorder, and all manner of things that can go wrong. Likewise, malfunctions in other processes tend to have similar shotgun effects.
• It is more helpful to think of genes switching on and off certain mechanical processes in the brain than “causing” a specific disease. Moreover, these processes work in the context of whole brain systems interacting with other brain systems, which may exacerbate or mitigate the effects of the equivalent of a tap not being able to shut off.
• There are no “good” genes or “bad” genes. Inevitably, there are trade-offs. A gene variation that may predispose you to stress may also protect you from Alzheimer’s.

To give us a better understanding of the brain in action, it is useful to look at the impact of other genes. Of all things, Dr Oakley’s list and my list are virtually identical. This is no accident. Daniel Weinberger of the NIMH is Oakley’s main source. Likewise, he is mine. Dr Weinberger was part of the team involved in the breakthrough research into the serotonin transporter gene, and he and his NIMH colleagues have been involved with the following, as well:

Brain-Derived-Neurotrophic Factor (BDNF)

This protein is involved in brain cell maintenance and survival and encourages the growth of new neurons and neural connectivity. A “double-val” variation in this gene has been linked to stronger memory. The catch is those with the double-val are prone to more anxiety and moodiness and hostility, possibly due to a magnification of the serotonin transporter glitch. A “double-met,” on the other hand may offset the glitch.

Catechol-O-methyltransferase (COMT)

Mechanically, this gene breaks down dopamine and other neurotransmitters. The more slowly you metabolize dopamine (the “met” variation), the smarter you are. The unfortunate “val/vals” may be a bit less intelligent, with a slightly increased risk of schizophrenia, plus risk of antisocial behavior, and hyperactivity. The “val/mets” fall in between. The trade-off? Vals may be able to handle stress better than the mets and be more flexible to change.

Monamine Oxidase A (MAO-A)

This protein breaks down dopamine and other neurotransmitters. Low-functioning MAO-A has been linked to aggressive and antisocial behavior and substance abuse and more. Those with low-efficiency versions of this gene tend to display hyperactive amygdalae (involved in fight-or-flight) and low-responding orbitofrontal and cingulate cortices. In other words, the front end of the brain has problems turning down the alarm signals from the back end of the brain. Impulsive violence may be one result.

A breakthrough 2002 study found that maltreated kids with low-efficiency MAO-A developed significant antisocial problems while the high-efficiency MAO-A kids were better able to weather the storm.

Wrapping it Up

Don’t worry about understanding all the fine details. The purpose here is to simply display how the interplay between genes and environment affect thinking and feeling and behavior. We are a long way from definitive answers, but we are definitely looking ahead to what 2000 Nobel Laureate Eric Kandel describes as “the new science of the mind.”

We don’t have to wait for psychiatry to get with the program. As I said at the beginning, we can apply brain science to our own recovery right now. Dr Oakley makes it abundantly clear that our behaviors are far less governed by free will and reason than our over-sized egos would have us believe. But knowing that, we can intelligently take stock of our vulnerabilities and make the type of course corrections that allow us more control over our brains and, with it, our lives.

Be smart. Live well ...

Jill Bolte Taylor Discusses the Brain and Recovery

“Am I safe?”

That is your brain’s bottom line, the question - the one question - that your temporal lobe, amygdala, and hippocampus are asking, moment by moment. When you’re not safe, learning and memory turn off.

The amygdala, which mediates fear and arousal, is engaged in a constant dialogue with its next-door neighbor the hippocampus, responsible for laying down memory, in partnership with the temporal lobe, at least when things go right.

Ultimately, as Jill Bolte Taylor, author of “My Stroke of Insight,” explained at the NAMI national convention last week in Chicago, our job is to create energy where we feel safe. Dr Taylor was climbing the career ladder as a neuroanatomist at Harvard when in 1996, at age 37, she suffered a debilitating stroke that left her unable to walk or talk or recall life. Her recovery took eight years.

Dr Taylor’s tour de force presentation at NAMI completely belied the fact that she had ever so much as suffered a single isolated synaptic misfiring in her entire life, let alone her entire world extinguishing in a catastrophic neurological supernova, but the explanation for her recovery, she let us know, can be summed up in one word: neuroplasticity.

Two words, actually: Neuroplasticity and neurogenesis.

Neuroplasticity, Dr Taylor explained, is about cells supporting cells in a network. It’s all about circuitry, but nothing is hardwired. Our neural connections are forever readjusting and strengthening - with dendrites unplugging from old neurons and replugging into new ones in response to new challenges.

Neurogenesis is about the individual cells and what they need in order to recover.

“The bottom line,” Dr Taylor said, “is we can choose where we can take our nervous system.” Literally, we can change the game. “I am neurocircuitry - thoughts, emotions, physiology. I can pick which circuits I want to run.”

“Pay attention to what you’re running,” she went on to say. “You get to pick and choose what’s going on inside your brain.”

It’s all about the amygdala. “I see your amygdala,” Dr Taylor told her audience. “Happy amygdala? That’s the bottom line for me.”

It all comes down to this: When the amygdala feels safe, the rest of the brain can do its job. Recovery is possible, but it doesn’t happen overnight.

“Give my brain time to recover,” Dr Taylor implored her audience. “Neurons are in very slow motion.” They also need rest, not overstimulation - sleep, lots of it, if that is what it takes to feel energized, even if only for short stretches of time. Her mother, she said, went completely against protocol in letting her sleep - which ultimately allowed her to heal.

Safety, time, rest - is healing really that simple? Think what the word, asylum, means. Maybe the answer has been staring us in the face all the time.

Much more to come ...

Never Mind Our Illness - What About the Real Stuff?

The following originally appeared as two unconnected blog posts in 2009. Last month, I connected them into a new article on mcmanweb ... 

"What is holding you back most in your recovery?" I asked readers at Knowledge is Necessity in March 2009. Readers were free to check off as many of the nine answers as they wished. (169 respondents accounted for 490 answers, averaging 2.9 answers per person.) You could have knocked me over with a feather with the results:

Only 35 percent of those who responded checked off, "Unresolved illness symptoms." In other words, a full 65 percent felt that their illness no longer posed an obstacle to their recovery.

Does this mean psychiatry has a high success rate? Um ... not exactly. In a survey from two months before, only 14 percent told me they "were back to where [they] wanted to be or better than [they] ever could have imagined."

What is going on here? Could it be that we have other stuff we need to deal with? This is where it gets interesting.

Interpersonal Relationships

Fifty percent (representing by far the largest total) responded that the thing holding them back the most was "fears/difficulties in dealing with people." Very closely related (at 35 percent) was a "bad living/work/etc" situation.

Clearly, we have major interpersonal issues that need addressing. Without doubt, our respective illnesses play havoc with our ability to get along with people. But my readers seemed to be telling me was that people problems have taken on a life of their own, and it's not hard to imagine why.

Often, we can't go back to our old relationships or work. As we become isolated and cut off, our social skills atrophy. We lose confidence. We are overwhelmed.

In essence, half of those who responded to my survey are telling me that they see the world as a threatening and hostile place, and this does not bode well for recovery. We tend to judge personal success by how well we get along with others. Unfortunately, there is no magic pill to help us. But there exists a lot of therapeutic and social help. You - yes, you - have identified this issue as your top priority. Please do not hesitate to act.

Fears and Anxiety

Also related to this (at 32 percent, one in three) is "inability to manage fears, impulses, etc apparently unrelated to your illness." Maybe you don't attribute, say, anger, to your illness. Maybe you talk too much or are afraid to speak up. Maybe going with an irrational thought makes you feel good. These are common problems that the general population also experiences, but you have added this twist - your sense of lack of control is holding as many of you back in your recovery as unresolved illness symptoms.

Your clinician may have overlooked all this, but clearly you haven't. You know what you need to do.

Bad Habits, Side Effects, Addictions, Ailments

We all have "bad personal habits" (even those with good personal habits), but 36 percent felt these were impeding their progress. Likewise, 30 percent reported that "making excuses" constitutes a major problem.

Overcoming bad habits, of course, falls into the same category as keeping New Year's resolutions. Good luck - you have your work cut out for you.

Finally: Meds side effects (24 percent), addictions (21 percent), and physical ailments (21 percent).

Tying This Into a Bow

There is no such thing as "just depression," "just bipolar," "just anxiety," and so on. A lot of other stuff is going on. Whether wrapped in your illness or independent of it, it all needs to be addressed, because if it isn't - recovery is simply not going to happen

A Reader Weighs In

Louise commented that "many, many people do not want full recovery because it would force them to take full responsibility for their lives and relinquish the power of being 'needy.'"

It happens a lot in physical illnesses, she was quick to add, patients who refuse to follow doctor's orders. For instance:

In the case of my friend's mother, she actually refuses to drink WATER. She wants alcohol and coffee, saying they "taste" better. She is in RENAL FAILURE. She is also a total "victim" control freak making her adult kids jump for every crisis - which she creates.

We all work hard to support and encourage our less-healthy loved ones to recover and live "full" lives again. But what if they don't really want to?

As for those with mental illness: "Some may say people with mental illnesses are not really making this 'choice.' But I can attest that many people with no strong mental illness problems DO make this choice everyday."

Louise was talking about willful disobedience rather than willpower, which other readers brought up. Hold that thought ...

In the meantime, Louise's comments got me thinking:

I certainly did not wish to stay sick, but I do acknowledge that being sick conferred on me a certain degree of absolution. Instead of regarding myself as an underachieving screw-up - in my own mind anyway - I could view myself as someone who overcame tremendous odds.

For the first time in my life, I actually gave myself a pat on the back.

But this came at the price of seeing myself as my illness, rather than seeing myself as me. Which meant I was encouraging people close to me to see me to also see me as my illness. Seeing myself as my illness worked for me for a little while. It gave me a fresh start. It allowed me to take stock. But once I got my illness under control, there was the small matter of working on the stuff that was really holding me back. The real work was only just beginning.

Dean Ornish Weighs In

Two months after my reader poll, I was in San Francisco, at the American Psychiatric Association annual meeting. There I heard celebrity doctor Dean Ornish of UCSF talk about smart lifestyle. For instance, in a 1998 study published in JAMA, Dr Ornish found that patients can not only stop the progression of heart disease through lifestyle management, but can actually reverse it.

In fact, smart lifestyle reliably works across a range of illnesses (including depression), and can often replace invasive and costly treatment (or at least make the treatment work better). The catch is you have to do it, and therein lies the problem. "What's sustainable," Dr Ornish said, "is not fear of dying but joy of living."

Dr Ornish is no stranger to depression, having experienced a severe episode that sidelined him from college. Loneliness and isolation, he said, increases mortality 3.7 times. Depressed individuals are more likely to over-eat, smoke, drink, and work too hard.

You would think that making a few simple changes would be easy, right?

"'Dean, you don't get it,'" his patients told him. "'These behaviors get us through the day.'"

Getting through the day anyway they could was more important to them than living to age 86. In essence, these people could see no benefit to giving up smoking if it meant losing their cigarette-smoking friends, especially if there was nothing to replace those friends.

Meanwhile, the research on the benefits of positive lifestyle kept mounting up. In one 2008 study published in PLoS (JA Dusek lead author), researchers found that the relaxation response in trained meditators switched off cancer-promoting genes.

Changing our lifestyle actually changes our genes, Dr Ornish pointed out. But who wants to change their lifestyle? What Dr Ornish finally figured out was that will power was a nonstarter for individuals, as was the motivation to live longer. "Who wants to live long if you're depressed?" he asked.

What works, he said, is joy, pleasure, freedom. Up went a slide of two tango-dancers - Dr Ornish and his wife. Doing the tango was part of Dr Ornish's exercise routine.

That's when the lightbulb went off: Yes, we need to lead disciplined lives, but we are doomed to failure unless we incorporate fun into our routines. Here, in this Recovery section, are numerous articles about the virtues of good diet, exercise, yoga, meditation, and so on. We know all this stuff works, but what good is any of it if we give up?

Then it occurred to me: None of my lifestyle routines are based on iron will. They all have enjoyment incorporated into them. For instance, my "exercise" is daily walks, water volleyball, and (off and on) dancing. My "diet" is based on my love of cooking, where anything I throw together is both tastier and healthier than restaurant food. My "stress-management" is all about building contemplative time-outs into my schedule. Even my "meditation" has a fun twist - I play the didgeridoo.

In the words of Dr Ornish: "Doing the tango makes your brain grow ... Some of the things that are most fun are good for you."

Glad I thought of it.

***

My previous three pieces reviewed a randomized, double blind, placebo-controlled clinical trial - representing the gold standard of scientific research - that told us nothing. My humble little reader poll, on the other hand, does not even meet the lowest standards of research. But I ask you: Did it tell you something?

Earth to Psychiatry: We Want to be Well, Not Just Stable

My last three blog pieces covered the main points I gave in a grand rounds to clinicians at a psychiatric facility two years ago in Princeton. There, I was accorded the same reception as Bill Gates at an Apple convention. Really, it went almost that well. Anyway, here is a major point I nearly overlooked, well worth underlooking ...

I clicked my PowerPoint. "The concept of maintenance is fundamentally flawed," read the slide.

Frozen Kelvin grade silence. Oh, shit, now what?

I had already told them that simply sending a patient out the door with just a prescription is not treatment, that we don't want to be like them, that from where I stand they all have flat affect, that there is a reason that all the pharm reps who visit them look like Heidi Klum or Russell Crowe, and that when their patients complain to them about feeling like fat stupid zombie eunuchs on the meds they prescribe and overprescribe we are not doing this to ruin their day.

Geesh. It wasn't like I was accusing them of something major, such as dancing like a white man. Okay, maybe they read that into my flat affect observation.

By way of background, treatment roughly divides into two categories: Acute and maintenance. There is a further distinction involving maintenance vs continuation treatment, but we won't go into that.

Acute treatment is short term. Typically, we are in a state of crisis. Psychiatry is very good at getting us out of crisis and into a state of stability. What I would call a state of undepression, unpsychosis, unmania, unanxiety, and so on. But then what?

Maintenance treatment seems based on keeping us in this stable state. But here's the catch, I explained. We're stable, but not well. The confusion seems to stem over the definition of remission. Up went a PowerPoint slide from Dorland's Medical Dictionary with this old world view:

Diminution or abatement of the symptoms of a disease.

But back in 2002, I came across this, from the American Psychiatric Association Bipolar Treatment Guideline issued that year:

Complete return to baseline level of functioning and a virtual lack of symptoms.

Here's how the APA links treatment to remission:

Treatment is aimed at stabilization of the episode with the goal of achieving remission, defined as a complete return to baseline level of functioning and a virtual lack of symptoms.

In other words, it's not good enough for our clinicians to have us feeling merely less miserable than before. You can also read into this that any trade-off between reducing symptoms and major side-effects is totally unacceptable. After all, how can we lead satisfying (ie functioning) lives when the thinking and feeling parts of our brains are off-line, not to mention what's going on elsewhere with us?

Thus, contrary to popular belief, there is no distinction between the medical model and the recovery model. The APA nailed "recovery" in their 2002 Guideline. In theory, we are all on the same page. But this principle has yet to percolate throughout psychiatry.

Up went this PowerPoint:

Instead of "acute" and "maintenance," I choose to distinguish between the crisis, stabilization, and recovery phases of our illness. During the early phases, with our illness at its worst and our knowledge and insight at its least, we are nearly totally dependent on psychiatry and medications, and we would be fools to believe otherwise. Then, in a best case scenario, as our skills and insight improve, we become less reliant on psychiatry and medications and become more active in our own recovery.

The stabilization phase is where the doctor-patient relationship begins to change. The patient is out of crisis, with significantly reduced symptoms, but is merely better and not well. Moreover, he or she is likely contending with serious meds side effects. Nevertheless, the patient is in a position to intelligently discuss his or her illness and treatment options, and wants to move on to being well.

So, here's the deal: Getting patients from crisis (acute phase) to stabilization (maintenance phase) is only half the battle, the easy half at that. The real work lies just ahead. Up went this PowerPoint, from a 2004 international bipolar treatment guideline:

The real key to treatment of bipolar disorder is successful maintenance treatment.

The catch is there is no reliable evidence base for maintenance treatment. Virtually all psychiatric meds studies focus on short-term treatment for patients in the acute (crisis) stage. This from the Depakote product labeling:

The effectiveness of Depakote ER for long-term use in mania, i.e. for more than 3 weeks, has not been systematically evaluated in controlled clinical trials.

Now had I really wanted to insult my audience, I would have asked them why the friggin' hell are you treating us at this stage with industrial-strength doses as if we're 911 cases bouncing off the ceiling when maybe all we need right now is just a teensy bit to take the edge off.

Think about it: If you have a broken leg, you don't wear a cast the rest of your life. But I spared my audience all this. See, I do exercise restraint. Then I had to ruin it all by clicking on my infamous slide:

The concept of maintenance is fundamentally flawed.

All the maintenance studies that I am aware off use as their measure of success relapse prevention, often expressed as time to relapse. So, here we are - stuck - unable to move forward, like a paleolithic hunter entombed in a glacial ice sheet, and psychiatry is celebrating because we're not back where we started. But actually the opposite is true. In virtually all these studies the relapse rates are horrendous.

Here's how Eli Lilly spun a 2006 Zyprexa maintenance study result:

Compared to placebo, olanzapine delays relapse into subsequent mood episodes ...

This appeared as an abstract in the leading psychiatric journal, the American Journal of Psychiatry, which means it turned up as the opening to the article and in all the various medical databases such as PubMed. Who, after all, reads entire journal articles?

What really happened was that eight in ten of the Zyprexa patients dropped out of the study.

"Does everyone agree this is highly deceiving?" I asked my audience. Thankfully, every head in the room bobbed up and down.

"I would go further," I replied. "I would call it immoral."

Kelvin grade frozen silence. Seems I just can't keep my mouth shut.

Is the Psychiatry of 1952 More Relevant to Our Recovery Than the Psychiatry of 2010?

From my keynote I gave to the DBSA Kansas State conference in Kansas in late April ...

Let’s turn to another researcher I heard speak in San Francisco.

This is a guy called Robert Sapolsky of Stanford. And he has dedicated his life to studying stress. So, Dr Sapolsky asks us to imagine a rat who has been trained to press a lever to avoid a mild shock.

Now, as he describes it:

The anticipation of mastery might induce a flood of dopamine to the frontal cortex and trigger pleasure. If the lever is disconnected, however, so that pressing it no longer prevents shocks, the rat will frantically press the lever repeatedly, attempting to gain control.

This, says Dr Sapolsky, is the essence of anxiety.

In human terms, I would describe it this way. Imagine waiting for a hot date to show up. The anticipation of a great night ahead triggers pleasure. But then the date doesn’t turn up on time. Pleasure changes to anxiety. And then it looks like the date will not turn up at all. So, to return to the rat, the real rat, not the no good bastard:

The shocks continue. The rat finds its attempts at coping useless. The rat basically gives up. Key neurotransmitters are depleted while stress hormones increase. In the words of Dr Sapolsky: The rat “has learned to be helpless, passive and involuted. If anxiety is a crackling, menacing brushfire, depression is a suffocating heavy blanket thrown on top of it."

That's a pretty good description, right? Says quite a lot about what we go through.

So, here you are. You’re all dressed up with nowhere to go. In the space of an hour or two, you have gone from pleasure to anxiety to depression.

Is this normal? Yeh, of course it is. The front end and the back end of the brain are working exactly as they should be. Yes, the result sucks, but if we have any kind of feelings at all, depressed is the state we’re supposed to be in.

Now, in a resilient brain, we will bounce back. Life may suck, but we cope, life goes on.

But suppose our brains are vulnerable. Say we don’t bounce back. Say we start thinking we’re worthless. Say we start over-ruminating. We lie in bed all day. And say this goes on for four months.

I’m going to finish up in a bit, but I want to throw another one at you here. I’m sure you’re aware that earlier this year the DSM-5 Task Force came out with a draft. Are people aware of that? Okay, good.

To keep it short: The DSM is due for an update in 2003. And this is the diagnostic Bible - okay? - put out by the American Psychiatric Association. No - 2013. Is that the same as two thousand - I don't know. I'm one of these guys who doesn't know if three-fifths is more than half or less than half.

Anyway, the DSM-IV is the current edition, which came out in 1994, and that's based on the DSM-III Revised which came out in 1987, which in turn is based on the DSM-III which came out in 1980, with hardly any changes all the way along. And guess what? The DSM-5 of 2013 is going to continue that tradition of making sweet F-all changes. So, basically, we're going to come out with a document that's going to set the tone for psychiatry for the next 20 years based on the DSM-III of 1980 and its ridiculously - stupid - criteria for depression.

Anyway, while I was doing my research, I dug out the old DSM-I from 1952 and the DSM-II from 1968. Basically, these are much the same and they're supposed to represent ancient history, you know, before psychiatry got modern, stuck in 1980 Ground Hog Day forever. Much of the DSM I and II had to do with this Freudian artifact called “neurosis.”

Well, guess what? According to these ancient DSMs, depression was a form of neurosis. Okay, fine. And guess what drove neurosis? Anxiety!

That’s not all. These ancient DSMs tried to break down mental illness two ways: That which they saw as biology-based - which they didn't have a clue about -  and that which was the result of a maladaptive response to stress.

So. Freeze-frame. Stress-anxiety-depression. Does that sound very close to the language Dr Sapolsky was using? Is the psychiatry of 1952 more relevant to our recovery than the psychiatry of 2010?

Well, in one sense, yes. The psychiatry back then was interested in looking under the hood, but they lacked the means. No brain scans. No gene tests. The best they could do was speculate about neurosis.

The old psychiatry also had no idea that stress was related to biology. They thought that just about all mental illness was a product of the mind as distinct from the brain. Nevertheless they knew that true recovery involved digging below the surface, deep into the mind. The catch was the only tool at their disposal - psychoanalysis - really didn’t work for most people. And it really didn't get patients all that much better.

Well these days, we know a lot more about recovery. There are a lot of tools available to us. We know a lot of them have very good success rates, and we heard a lot about that this morning.

After lunch, I will be giving another talk. I’m looking forward to concentrating more on recovery tools. And you will also hear more speakers talk about recovery. But what I want to emphasize here is:

Recovery starts with knowledge. It helps knowing that we have vulnerable brains. That the back and front ends of our brains don’t always act the way they should. That they don’t always talk to each other the way they should. That we have a tendency to over-react. That we also have a tendency to both over-think and under-think.

Not only that, our brains are slow in resetting to normal.

What this means is - instead of coping with life, life becomes a struggle.

Do we have some kind of consensus on this? We're on the same page with this? Because - you know - you really get this wisdom going to DBSA support groups and also NAMI groups. And other groups. There's a lot of patient and family wisdom there.

Mental illness is simple, really. We get overwhelmed, overloaded. Too much of one thing, too much of everything. Too much thought, too much emotion, too much sensory input. Too much of nothing, even. Think of a fire in your brain or of being trapped deep underground, unable to breathe. There is no way the brain can respond rationally.

The brain copes, instead, by flipping out or shutting down.

But this doesn’t mean we have to give up. It only means we have to work harder and smarter.

So - know thyself. Look under the hood. Check out what’s really happening inside. Take nothing for granted. Question everything.

So here we are, on our journey, somewhere in the Land of Oz, looking to return home, to Kansas ...

Why Are You Asking Me?

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

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

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

"Living Well with Depression and Bipolar Disorder" was the result of six years of writing on my illness. In January 1999, after a crushing round of severe depressions and a lifetime of denial, I was diagnosed with bipolar. I had been a financial journalist, and now I turned to writing about my illness, first for a website, then my own email newsletter, then my own website.

I was not afraid to write about my personal experiences, but first and foremost I considered myself a reporter. I went to the same conferences psychiatrists and researchers went to. I read their journals. I listened, I asked questions. I also listened to another group of experts, patients and loved ones.

I may have connected the dots in a way that no one else had before, but the book wasn't about me. I was simply passing on wisdom and insights I had learned from others and I had at least 300 footnotes to prove it.

But, in public, the audiences I spoke to had entirely different perceptions and expectations, which I failed to register for the longest time. For instance ...

NAMI's membership in large part comprises the parents of individuals with severe mental illness (mainly schizophrenia). These parents have struggled with a health care system that seems specially designed to fail their sons and daughters. Most have been told their kids will never get well. Then, they see me - me with a diagnosis - speaking to them on a very complex topic without notes.

For instance ...

DBSA is run by patients living with depression and bipolar. I'm one of these individuals. We all learn from one another, which can only work if we all accept each other as equals. Thus, an individual on disability brings the same insight and wisdom to the table as someone who has just been awarded a McArthur Genius Grant. But DBSA groups do bring in expert speakers, and suddenly I was one of them.

One day in the spring of 2007, at a DBSA group in Washington DC, someone happened to ask me this: "What do you do for your own recovery?"

Why on earth do you want to know? I could only think. I'm the same as the rest of you.

Ask me about the fine points of brain science, I wanted to respond. Grill me on the ins and outs of diagnosis and treatment. Diet, exercise, sleep - no problem. I had the expert answers at my finger tips and I didn't even need a life line.

Hannibal crossed the Alps with elephants, Abyssinia is what they used to call Ethiopia, and when Emil Kraepelin coined the term manic depression back in the early twentieth century he was talking about unipolar depression as well as what we now refer to as bipolar disorder.

I was stumped. It made no sense to me that someone else would view me as some kind of example of recovery. I blurted out something incoherent, and waited to be rescued by someone wanting to hear me expound on neuroplasticity or spell opthamologist or something.

I was still living in denial when I gave two presentations at a national DBSA conference that summer in Orlando. One of the organizers, without consulting me, had put on the program that I would be talking about recovery. Ha!

No way I was going to lecture people in how to run their lives. Ruin their lives, perhaps - I was an expert at that. But run? You gotta be kidding.

Recovery starts with knowledge, is how I began. Here's some cool stuff I learned, was the gist of what followed. The rest is up to you. Oh yeh, and I broke up one of the talks with a didgeridoo interlude. (You can check out why didgeridoos make perfect sense to me here.)

That's not the way you work yourself up from break-out speaker to keynoter, I learned. Or, for that matter, ever get invited back to speak again, not with two audiences primed to hear about recovery.

Apparently, there was this thing called a recovery movement. Recovery is for YOU to figure out, I wanted to scream. It has nothing to do with me.

But a funny thing was happening. I was changing. The person talking about my book in the summer of 2007 was not the same person who wrote it in late 2004-early 2005. Recovery is a journey, they say. Mine began one crazy October morning nearly 60 years ago when I literally forced my way out of a birth canal that my mom, on doctor's orders, had been blocking by holding her legs together.

Then life intervened.

Much later, on a weird November evening in New Jersey, a certain stage of my journey came to a precipitous and definitive end. A new stage was opening up. A leap of faith, one-way to San Diego ...

More to come ...

Who the Hell Are We and What Does That Have To Do With Our Recovery?

Picking up from where we left off:

It turns out the most consistent way of recognizing that someone is in a state of well-being is how well they've been able to express self-directedness, cooperation, and self-transcendence in their lives.

This translates into meaningful work, mutually caring relationships, and a sense of what's really important beyond out individual needs.

So says personality and well-being expert Robert Cloninger MD of Washington University (St Louis). Dr Cloninger was addressing a packed house at the American Psychiatric Association's annual meeting last week in San Francisco. I was in the audience as a journalist.

Medications are useful in getting us to stable, Dr Cloninger advised, and in putting us in a position to get started. Then the real journey begins. It all starts with knowing ourselves, having a sense of growth and self-awareness.

So who the hell are we?

Well, before we answer that question, we might first ask ourselves to define personality. Dr Cloninger's simple explanation: "It's the way we learn and adapt." Let's amplify that: "It's the self plus the internal and external forces that pull on the self."

Key features of personality, Dr Cloninger said, include:

• It's dynamic, and non-linear. "Get over the idea that it's fixed and written in stone."
• It is psychobiological, which includes the body, the analytical mind, and the intuitive and creative mind.
• It is organized. There is a basic design in all human beings that allow us understand and to communicate with each other.
• It is personal. Adaptive processes occur within the individual. We tend to get sidetracked comparing the differences between people, which is wrong. If we want to motivate someone, we need to figure out what is going on within them, what counts to them.
• It is idiographic. We are each unique.

Here's a key fact we tend to overlook: We have evolved over millions of years, and with it three major systems of learning and memory.

1. Habits and skills learning: Reptiles have this nailed. This is based on the quantitative strength of our synaptic connections. It is prelogical, not rational, and subjectively linked to basic emotions such as fear and anger and ambition. These habit systems demand instant gratification and tend to get in conflict with each other.
2. Semantic learning of facts and propositions: Mammals rule in this department. It is contingently logical and rational in a hierarchical sense, and is associated with secondary emotions such as empathy. Propositions bring order to the chaos of the demands of our basic emotions, but is not self-aware.
3. Intuitions and narratives: A uniquely human trait, the recognition that we are writing our own story. At once, we talking about pre-verbal and intuitive, rational and self-aware, modular rather than hierarchical. Here's the pay-off: "It gives us flexibility about the future. We can change. We can have hope. We can be creative and do things we've never done in the past and surprise everybody."

Ah, now we're getting somewhere. We've just gotten past the Table of Contents. Now we can begin to check out our Owner's Manual in earnest. Think of the slide below as a sneak preview.













Trust me, "Know Thyself" is where recovery starts, and Dr Cloninger is the leading authority. Much more to come ...

What the Hell is Well-being, Anyway, and Why Is It So GD Important?

Good title for a talk? Psychiatry tends to veer toward wonky titles, such as: "Developing a Positive Psychiatry of the Person."

Okay, let's go with that. Last week in San Francisco, at the American Psychiatric Association's annual meeting, I heard Robert Cloninger MD of Washington University (St Louis) deliver the type of lecture that justifies his reputation as a pioneer in that strange field that we simultaneously know everything and nothing about: personality and well-being.

"Well-being is the universal wish of human beings," Dr Cloninger opened. "We all want happiness, love, and a meaning of life that is greater than our individual self."

Obviously, this is something that you can't get in a pill, and therein lies the problem with our treatments. Response to acute (initial phase) treatment, whether with meds or talking therapy, is only moderate, and drop-outs, relapses, and recurrences are high.

But if clinicians are smart, Dr Cloninger went on to say, they will attend to what people want in life and build therapeutic alliances around that. On the other hand: "Getting people to do things they don't want to do doesn't work well."

There are four converging ways to measure well-being, Dr Cloninger told his audience:

1. Emotions: Namely positive ones, ie being happy.
2. Personality: It turns out that positive emotions relates to maturity in character. People who have a well-integrated personality also turn out to be happy.
3. Life satisfaction: People who are content with their lives don't have a lot of complaints.
4. Virtues: People who have them (courage, justice, moderation, honor, wisdom, patience, love, hope, and faith) also tend to be happy, mature, and satisfied with life. Reframing a goal to work on developing courage, for instance, may produce a better outcome than figuring out what to do with an anxiety disorder.

Well-being has little to do with income. Rather, there is an association with heritable personality traits, plus with meaningful work, mutually caring friendships, and spiritual values. Dr Cloninger cited Ed Diener's pioneering work that showed while personal income in the US has dramatically increased from the 1930s to the present, life satisfaction has remained static.

Over this time period, we have seen the introduction of all our psych meds and all our manualized therapies. We know these things are helpful, Dr Cloninger said, but "why isn't it making a dent" in these statistics?

So what's the key to well-being? It all starts with self-awareness, Dr Cloninger advised.

Check out the name of this blog. Much more on Dr Cloninger to come ...

What Does the Tango Have To Do With Recovery?

As you know from reading this blog, last week I was in San Francisco attending the American Psychiatric Association's annual meeting as a journalist. What I didn't report was my biggest knock-me-over-with-a-feather moment. Allow me:

On Thursday morning, I listened to Dean Ornish MD of UCSF. Dr Ornish is a celebrity doctor and author known for promoting smart lifestyle choices as the key to good health. His recommendations are all grounded in rigorous research, much of it his own. For instance, in a 1998 study published in JAMA, Dr Ornish found that patients can not only stop the progression of heart disease through lifestyle management, but can actually reverse it.

In fact, smart lifestyle reliably works across a range of illnesses (including depression), and can often replace invasive and costly treatment (or at least make the treatment work better). The catch is you have to do it, and therein lies the problem. "What's sustainable," Dr Ornish said, "is not fear of dying but joy of living."

Hold that thought.

Dr Ornish is no stranger to depression, having experienced a severe episode that sidelined him from college. Loneliness and isolation, he said, increases mortality 3.7 times. Depressed individuals are more likely to over-eat, smoke, drink, and work too hard.

You would think that making a few simple changes would be easy, right?

"'Dean, you don't get it,'" his patients told him. "'These behaviors get us through the day.'"

Getting through the day anyway they could was more important to them than living to age 86. In essence, these people could see no benefit to giving up smoking if it meant losing their cigarette-smoking friends, especially if there was nothing to replace those friends.

Meanwhile, the research on the benefits of positive lifestyle kept mounting up. In one 2008 study published in PLoS (JA Dusek lead author), researchers found that the relaxation response in trained meditators switched off cancer-promoting genes.

Changing our lifestyle actually changes our genes, Dr Ornish pointed out. But who wants to change their lifestyle? What Dr Ornish finally figured out was that will power was a nonstarter for individuals, as was the motivation to live longer. "Who wants to live long if you're depressed?" he asked.

What works, he said, is joy, pleasure, freedom. Up went a slide of two tango-dancers - Dr Ornish and his wife. Doing the tango was part of Dr Ornish's exercise routine.

That's when the lightbulb went off: Yes, we need to lead disciplined lives, but we are doomed to failure unless we incorporate fun into our routines. On my website are numerous articles about the virtues of good diet, exercise, yoga, meditation, and so on. We know all this stuff works, but what good is any of it if we give up?

Then it occurred to me: None of my lifestyle routines are based on iron will. They all have enjoyment incorporated into them. For instance, my "exercise" is daily walks, water volleyball, and (off and on) dancing. My "diet" is based on my love of cooking, where anything I throw together is both tastier and healthier than restaurant food. My "stress-management" is all about building contemplative time-outs into my schedule. Even my "meditation" has a fun twist - I play (rather badly) the didgeridoo.

Then I flashed back to some of my recent blogs - a whole series on play, a bunch of home-made nature videos. Guess what? When it comes to fun, I am very compliant. My "fun" routines may not be as beneficial as "serious" routines, but they work much better by virtue of the fact that I stick to them.

In the words of Dr Ornish: "Doing the tango makes your brain grow ... Some of the things that are most fun are good for you."

Dang! Why didn't I think of that?

New Poll Results: Faith and Spirituality in Our Recovery

"How important is faith/spirituality in your recovery?" I asked readers here during the month of April.

Of the 200 of you who responded, nearly half (46 percent) rated "faith or belief in God" as a major part of your recovery. One in five (20 percent) regarded "spirituality" in the same light. In other words, a full two thirds of you (66 percent) regard your faith or spirituality as essential to your wellness. When we add another 12 percent who assigned a modest role to faith/spirituality, we are talking in terms of nearly eight in ten (78 percent).

Only 16 percent of you said faith/spirituality plays no role in your recovery while a mere handful of you (5 percent) thought faith/spirituality was an impediment to your recovery.

What to make of this? The two-thirds figure compares favorably to the eight in ten figure from an earlier poll result concerning the importance you assign to your meds. There is a crucial distinction, however: The faith/spirituality poll was framed in terms of RECOVERY while the meds poll was framed in relation to TREATMENT.

This distinction is crucial in regard to how we triangulate both these polls to yet an earlier poll that found only 14 percent of you reported that you were well. In light of that finding, I did not hesitate to suggest that your meds have let you down. Am I justified in coming to the same conclusion in terms of your faith and spirituality?

Not quite, no, definitely not. Treatment and recovery are like apples and oranges. In the treatment phase, our meds are doing all the heavy lifting, and we expect them to work. In the recovery phase, we know that relying on just one thing is not going to get the job done.

There have been a number of studies that convincingly demonstrate that people of faith recover more quickly from a variety of illness than their non-faith counterparts. But we're not talking knock-my-socks-off numbers. These are modest gains, precentage-wise, in the low single digits.

For our recovery to move forward, we need to incorporate our modest gains into other modest gains. The recovery literature is full of useful advice on reframing our thoughts, stress-reduction, improving our interpersonal skills, peer support, and working on smart lifestyle choices. Lately, mindfulness has been enjoying flavor-of-the month status.

It's a crowded field. We have a lot to choose from. So here's the significance of this month's poll result as I see it: Notwithstanding all the choices in our recovery we have, not withstanding all the attention commentators have devoted to these other choices, a full two-thirds of you assigned major importance to faith/spirituality.

Clearly, the people who are working with us in our recovery need to know this.

Why is faith/spirituality so vital to you? I'm guessing here, but I think it may have a lot to do with how well belief in something greater than ourselves blends with and enhances the benefits of our other recovery tools. Thus, maybe you pray to God to get you through the last phase of a strenuous physical workout. Conversely, maybe when you practice mindfulness you become aware of a higher presence, which in turn motivates you to get through the day. On and on it goes.

Finally, for most of us, faith and spirituality is a no-brainer. We've grown up with it. We're comfortable with it. So, when we finally start thinking about our own recovery, we are not contending with learning a new skill that may not be a good fit for us. Faith and spirituality is something we can incorporate into our recovery right now, with positive benefits. An overwhelming number of you - eight in ten - have told me you've already done that.

Blueprint for Recovery - YOU Are the Authority

Last week, I spent three days at a schizophrenia conference listening to some of the smartest people in the world, and I have the autograph of a Nobel Laureate (Arvid Carlsson) to prove it.

But the people I learn from the most is you - patients and loved ones - and I have this month's latest survey to prove it.

"What is holding you back most in your recovery?" I asked you over the month of March. Readers were free to check off as many of the nine answers as they wished. (169 respondents accounted for 490 answers, averaging 2.9 answers per person.) You could have knocked me over with a feather with the results:

Only 35 percent of you checked off, "Unresolved illness symptoms." In other words, a full 65 percent of you felt that your illness no longer posed an obstacle to your recovery.

Does this mean psychiatry has a high success rate? Um ... not exactly. In my January survey, only 14 percent of you told me that you "were back to where [you] wanted to be or better than [you] ever could have imagined."

What is going on here? Could it be that we have other stuff we need to deal with? This is where it gets interesting:

Fifty percent of you (representing by far the largest total) responded that the thing holding you back the most is "fears/difficulties in dealing with people." Very closely related (at 35 percent) is "bad living/work/etc" situation.

Clearly, we have major interpersonal issues that need addressing. Without doubt, our respective illnesses play havoc with our ability to get along with people. But you are telling me that people problems have taken on a life of their own, and it's not hard to imagine why.

Often, we can't go back to our old relationships or work. As we become isolated and cut off, our social skills atrophy. We lose confidence. We are overwhelmed.

Half of you are telling me that you see the world as a threatening and hostile place, and this does not bode well for recovery. We tend to judge personal success by how well we get along with others. Unfortunately, there is no magic pill to help us. But there exists a lot of therapeutic and social help. You have identified this issue as your top priority. Please do not hesitate to act.

Also related to this (at 32 percent) is "inability to manage fears, impulses, etc apparently unrelated to your illness." Maybe you don't attribute, say, anger, to your illness. Maybe you talk too much or are afraid to speak up. Maybe going with an irrational thought makes you feel good. These are common problems that the general population also experiences, but you have added this twist - your sense of lack of control is holding as many of you back in your recovery as unresolved illness symptoms.

Your clinician may have overlooked all this, but clearly you haven't. You know what you need to do.

We all have "bad personal habits" (even those with good personal habits), but 36 percent of you felt they were impeding your progress. Likewise, 30 percent of you report that "making excuses" constitutes a major problem.

Congratulations at setting out a recovery agenda: You need to change; no excuses. But do keep in mind: Change does not come easy. Set modest goals, forgive yourself when you mess up, and make full use of peer and professional support.

Finally: Meds side effects (24 percent), addictions (21 percent), and physical ailments (21 percent).

Take home message: There is no such thing as "just depression," "just bipolar," "just anxiety," and so on. A lot of other stuff is going on. Whether wrapped in your illness or independent of it, it all needs to be addressed, because if it isn't - recovery is simply not going to happen

I can say this with great authority, because this is what you - my valued readers - have told me. Be smart. Live well ...

Previous survey results:

Have Our Treatments and Therapies Failed Us?

Meds and Wellness: Like Rolling a Rock Uphill?