My Mother's Day News

Happy Mother's Day, mothers of the world and mothers-to-be. I have some personal news that I have been waiting for the right time to share. Here it is:

My daughter Emily is going to be a mother!

Which will make me a grandfather. She phoned me about two months ago from New Zealand, where she and her husband live. The baby is due in early October. Of course, this is the best news I've had since a time long ago and far away when I found out I was going to be a father.

Like any grandfather-to-be, I am concerned about the postpartum mental health of my daughter, and you can read my thoughts on this in Katherine Stone's Mother's Day Rally for Mom's Mental Health on her excellent blog, Postpartum Progress. The Rally features 24 "warrior moms" posting their thoughts throughout the day to new moms. (Scroll down the various entries to get to mine, but please read the other contributions.)

My daughter was born in New Zealand (I lived there for 11 years), grew up there, and calls it her home. Last year, in March, I attended her wedding there. She is the best daughter in the world. Out of respect for her privacy (and that of her family), that is all I will disclose about her. From time to time, I will bring you up-to-date on my life as a grandfather-in-progress.

And, of course, I will share the news when the big day arrives.

So to my daughter Emily, as well as my own mom and Emily's mom, plus all moms and moms-to-be - you are the best. You deserve our love and support. There is no such thing as a day off for a mom. So as well as wishing you a happy Mother's Day, my best wishes to you all the other days of the year, as well.

Mother's Day Rally for Mom's Mental Health

Tomorrow, fellow blogger Katherine Stone will be hosting a special Mother's Day rally at Postpartum Progress. Her blog is undeniably the best source of postpartum information on the web, which every mom-to-be, new mom, and their families need to be reading religiously.

Following her own recovery from postpartum OCD, in 2004 Katherine launched her blog. In 2008, WebMD honored Katherine as a web hero.

Tomorrow's event promises to be especially noteworthy. As Katherine explains in her blog:

The Mother's Day Rally for Moms' Mental Health is an online event featuring 24 open letters to new mothers on the importance of maternal mental health. All of the letters will be written by survivors of and experts on perinatal mood and anxiety disorders, including postpartum depression and postpartum psychosis, as well as by others who care about the emotional well-being of moms and moms-to-be.

Each hour, on the hour, for 24 hours straight, Postpartum Progress will post a different "Letter to New Moms". The letter writers were given a blank canvas to share their humor, experience, tips and ideas, focusing on the mental health of women during pregnancy and postpartum.

I'm proud to be included in Katherine's list of "mommy bloggers." What am I doing there? Stay tuned for my big announcement, tomorrow, Mother's Day.

Again, important reminder: Mother's Day Rally for Moms' Mental Health.

I'm a Tool of Scientology!

This is too funny for words.

Above is a screenshot from the Recovery page on my website McMan's Depression and Bipolar Web taken just a few minutes ago.

No, you are not seeing things. In the lower right hand corner, you are viewing an advertisement for the Church of Scientology. Like nearly everyone who operates a website or a blog these days, I employ Google Ads to help pay the rent. I do not - nor have I ever - solicited advertising. Rather, Google automatically loads advertisements that its various algorithms decide is a good fit for the page.

Apparently, the Google algorithm determined that I am a friend of Scientology.

In a similar fashion, HealthCentral loads ads into the top banner portion of my mcmanweb pages. At the time of this writing, for this particular page, an ad for Ensure is on display. Across another page right now is an ad for Prisiq, which looks like this:







Various antipsychiatry bloggers such as Philip Dawdy of Furious Seasons periodically (and tediously) attempt to discredit my writing based on the fact that I happen to carry these ads on my site.

Apparently I am a tool of Big Pharma.

But no, the conspiracy is even more evil and far-reaching. I'm also a tool of Scientology!

Okay, okay. I confess. It was me you saw on the Grassy Knoll one day in late November. Whew! It's a relief to get that out of my system. In the meantime, don't forget to support my sponsors ...

My Top Ten Mental Health Stories

Following is what I view as the ten most significant events or trends affecting all of mental health in my ten years researching and reporting on my illness. Obviously, had I been reporting on say schizophrenia rather than bipolar my list would be different. Then again, only one entry here is bipolar-specific. So, without further ado, in no particular order:

Recognition of child bipolar

Ten years ago, virtually everyone thought you had to be of voting age to qualify for a bipolar diagnosis. A lot of the credit for changing that misconception goes to the parents, who have taken it upon themselves to educate clinicians and educators. There has been a noisy public backlash over labeling and medicating kids, but the alternative of turning your back on them is totally unthinkable.

Key people: Demitri and Janice Papolos, authors of "The Bipolar Child"; Joseph Biederman, Harvard child psychiatrist and paradigm-shifter.

Bottom line: A child who jumps out of a moving vehicle has something very serious going on. Finally, we have woken up and are doing something about it.

Coming of age of borderline personality diagnosis

Surely, the thinking went, there could be no biological basis to this Freudian artifact. Guess what? The brain scans tell a different story. The scientific evidence, coupled with proof that interventions such as DBT work, not to mention the realization that borderline may be one reason why many so-called bipolar patients do not get better, is slowly shaking psychiatry out of its denial and raising public awareness.

Key people: Marsha Linehan, developer of DBT; Paul Mason and Randi Kreger, authors of "Stop Walking on Eggshells."

Bottom line: Countless individuals currently living tortured lives can look forward to a fresh start.

Brain science research

Where to start? The mapping out of stress-vulnerability and thought and modulation pathways, new revelations about plasticity and brain cell growth, new discoveries into how neurons work, new insights into how the brain interacts with the environment, the emergence of brain development as an explanation for mental illness, plus a host of candidate illness genes and the mapping the human genome ...

Key people: Eric Kandel, Arvid Carlsson, Paul Greengard, who shared the 2000 Nobel Prize in Medicine for their work in how neurons communicate.

Bottom line: Very smart people are changing the way we think, and - eventually - how we live.

Validation of talking therapies

CBT, interpersonal therapy, and other short-term therapies focusing on the here and now have been around since at least the seventies. But only in the last decade do we have the studies to prove just how useful these interventions are. Their popularity is growing, along with new applications, including CBT for schizophrenia (once regarded as a waste of time).

Key people: Aaron Beck and David Burns, founder and popularizer of CBT, respectively.

Bottom line: Growing numbers are learning to actively take charge of their own brains.

The spectrum concept

It's not whether you have bipolar - it's how much bipolar you may have. In other words, your depression may be more than just depression. In addition, the spectrum concept is encouraging researchers and clinicians to more closely examine various relationships between supposedly separate illnesses such as schizophrenia and autism - not to mention how such things as temperament and illness interact - and come up with original insights.

Key people: Hagop Akiskal, bipolar spectrum proponent; Robert Cloninger, personality pattern-spotter and paradigm-shifter.

Bottom line: The brain is not organized according to the DSM. Thank heaven for that.

Recovery movement

Earth to psychiatry: We want to get well, not just stable. We want to have lives, not just subsist as over-medicated zombies. In response, patients have taken matters into their own hands, with a growing grass roots recovery movement that trains peer specialists and encourages patients to take positive steps to move their lives forward.

Key people: Mary Ellen Copeland, proponent of WRAP; Daniel Fisher, recovery rabble-rouser; Eugene Johnson, founder of Recovery Innovations.

Bottom line: Psychiatry makes us stable. Only we can make ourselves well.

Patients and loved ones figure out the internet

Suddenly, we weren't alone and isolated. We could talk to each other online, support each other, learn, organize, and advocate. In addition, we could find information on our own from expert sources, then become our own experts. The downside, of course, is what happens with this tool in the hands of the ignorant and unprincipled.

Key people: Martha Hellander, founder of the Child and Adolescent Bipolar Foundation, the first internet-based mental health advocacy organization; Peter Frishauf, founder of Medscape; Deborah Gray, founder of "Wing of Madness," the template for many patient sites to follow.

Bottom line: For better and worse, the internet is where most of us go to for information and support.

Beginning of the end of drug companies

Everything seemed to happen at once: Patients and doctors seeing through the Pharma hype, blockbuster meds losing their patent protection, and no new meds coming out of the pipeline. No longer with any financial interest in influencing psychiatry, Pharma virtually backed out of the game. And with mega lost revenues from loss of patent protection, Pharma may lack the resources to ever get back in it.

Bottom line: Due to their arrogance and stupidity, Pharma fully deserves what's coming, but do we?

Deterioration in services

Not being able to afford meds and the doctors who prescribe them is only a small part of the problem. Lack of access to costly and time-consuming services is major. You name it - long-term therapy, psychiatric rehabilitation, higher education, crisis intervention, social services, vocational training, jail diversion, decent housing - not only is the money not there; the system is seemingly designed to fail us.

Bottom line: In this economy, things are only going to get worse.

Returning vets mental illness time bomb

Vets are returning from Iraq and Afghanistan with high rates of mental illness, or at high risk of mental illness, including PTSD and depression. Add to that the challenges in fitting back into society, then consider what many do to cope, such as drugs and alcohol.

Bottom line: Vietnam vets account for a large percentage of the homeless. Unless we act fast and plan long term, a new generation of vets will join them.

Big story of the next ten years: The current economic crisis

Whichever way events play out, society's most vulnerable will be the hardest hit, and those better off aren't immune either. Nevertheless, before we predict a pandemic of stress-related mental illness, the data shows that people actually experience better health and live longer when times are bad. Something to do with a return to core values?

Bottom line: However we come out of this, nothing is ever going to be the same again.

The Borderline Personality Disorder Matzoh Ball

My final (for right now) Borderline Personality Disorder Awareness Month installment:

Until just a very short time ago, psychiatry treated borderline personality disorder as one big matzoh ball on the table. Freud and his followers, of course, were to blame for the embarrassment. If only these idiots were to go away, the thinking went, they might take their matzoh ball with them.

Then, psychiatry conceded that yes, the matzoh ball was here to stay, but where to put it? In the schizophrenia casserole? In the bipolar stew?

The borderline matzoh ball didn't deserve it's own dish. A soup, maybe, but certainly not a soup of the day, and definitely not where customers could find it on the menu.

Real mental illness involved scientists talking about tangible stuff such as heritable traits and brain biology, not Freudian cultists babbling nonsense about emotional attachments and integrating aspects of one's self.

Get over it, psychiatry. The borderline matzoh ball is not only here to stay, it rates a featured place on the specials board. In 2008, the NIMH reported on a series of brain imaging studies led by Michael Minzenberg MD of the University of California, Davis.

Previous brain scan research pointed the way by linking a wide range of behaviors to heightened activity in the primitive limbic regions of the brain, most notably the amygdala which mediates arousal and fear. Thus, a hypersensitive limbic system, in response to stress or even just perceived stress, may override the thinking cortical areas of the brain.

In short, people go crazy. Depression, anxiety, mania, aggression, and psychosis are just some of the possible responses. Individuals vulnerable to stress also tend to behave destructively, such as reaching for the bottle or over-eating or sexual promiscuity or self-harm.

There is an added complication: While the limbic region of the brain appears to be overdeveloped, certain cortical regions - most prominently the anterior cingulate cortex (ACC) - appear to be underdeveloped. The ACC, it turns out, is wired into the limbic fear hub.

Perhaps you see where this is going: The ACC acts as a key modulator to limbic over-excitement, and when this part of the brain is not booting up right, the thinking parts of the brain are not only taken off-line, they remain out of commission long enough for people to notice.

In the first study, Minzenberg and colleagues compared the brain scans of borderline patients with healthy controls. While in an MRI machine, the subjects viewed images of "scary faces" (a very common experiment in functional or fMRI). Predictably, the borderline patients displayed overactivity in the amygdala and underactivity in the ACC. In the words of the NIMH:

"Since ACC activity would normally increase to dampen an overactive amygdala, this suggested weak regulation of emotion in the circuit."

Next, the researchers employed structural or anatomical MRI to compare grey matter in the same subjects. The studies found that relative to the controls, the borderline subjects showed increased grey matter density in parts of the amygdala (image below top, red areas) and decreased grey matter in parts of the ACC (image below bottom, yellow area at right). As the NIMH describes it:

"This suggested an abnormality in the number or architecture of neurons in these key components of the emotion-regulating circuit, which other evidence links to impaired functioning of the serotonin chemical messenger system."




















Some quick disclaimers here. The amygdala and the ACC and its connecting circuitry have been implicated with regard to depression and other behaviors. Thus, these studies cannot be cited as irrefutable proof of the borderline diagnosis. For that to happen, we would have to find out what is wrong in the brain that is unique to borderline (or for that matter any other mental illness) and then connect the dots.

What the brain scans do show is that borderline undeniably shares a similar pattern of underlying brain dysregulation as other illnesses regarded as biological, on the same order of magnitude as bipolar and schizophrenia and the rest.

We can even take it a step further. Think of borderline as a condition where its victims constantly view the world as threatening and unpredictable. So, when we're discussing fear factor miscues in the brain, which illness does it best apply to? So ...

Get ready, which illness then becomes the featured dish of biological psychiatry?

Holy cow! The humble Freudian matzoh ball.

Further reading from mcmanweb:

Psychiatry's Big Bang

In addition, an NIMH study under review shows the ventromedial prefrontal cortex modulating amygdala activity through the cingulate. Ah, a part of the brain associated with "thinking," your protection against lashing out like a caged beast. Thus, if you happen to be in the middle of a heated marital dispute, this is probably the time to draw in a slow breath and very calmly say, "I hear you. I think we can work something out."

If your amygdala is doing the talking, however, it may come out something like this: "And besides, you’re lousy in bed!"

At this stage, storming out the door in a huff may be your best option. The amygdala is getting through to the cortex, but the cortex is clearly having difficulty getting through to the amygdala. You probably will be sleeping on the couch tonight, but thankfully you can count on your cortex not to let your behavior escalate from regrettable to extreme. But suppose your top-down circuitry is faulty?

As Dr Meyer-Lindenberg explained, we need a breakdown in the brain’s control mechanisms to become violent. ...

Piecing Together the Borderline Puzzle

May is Borderline Personality Disorder Awareness Month. Our story so far:

In 1980, borderline personality disorder received formal recognition as a diagnosis with its inclusion into the DSM-III. The catch was that the illness was consigned to "Axis II," widely regarded as psychiatry's wrong side of the tracks. As an editorial by John Oldham MD of the Menniger Clinic in this month's American Journal of Psychiatry explains:

The decision derived from the belief that borderline and other personality disorders were "caused during early development by parental neglect, abuse, or inconstancy." The prototypical image of a patient was that of an angry volatile individual prone to reject help, blame others, and behave self-destructively. "Too often, this behavior was seen as willfully oppositional, and borderline personality disorder patients were spoken of as dreaded pariahs."

Our current clinical and scientific knowledge, Dr Oldham advises, is changing those perceptions. Core "heritable endophenotypes" of affective dysregulation and impulsive aggression have been identified. Brain scans reveal specific abnormalities, namely a hyperactive limbic system, in particular the amygdala (which mediates arousal and fear). Thus, certain individuals are primed to overanticipate and overreact when their personal dealings hit a snag.

This state of emotional overdrive is difficult to extinguish, owing to impairment in the cortical areas to inhibit this limbic-driven emotionality or impulsivity.

As if this isn't bad enough, this phenomenon of "brain gone wild" interferes with forming emotional attachments during child development, which may be magnified by lack of adequate parental support. As Dr Oldham describes it:

"These combined etiological factors produce arrested, distorted, or incomplete integration of aspects of self and others, resulting in early onset and persistence of profound interpersonal difficulties. Normal early development becomes derailed, and the crucial developmental milestone of basic trust is not achieved."

No wonder no one has come up with a med to treat borderline patients. As a second editorial - by Otto Kernberg MD and Robert Michels MD of Cornell - explains, only 30 percent of patients with borderline respond satisfactorily to meds over the long term.

(Editorial sidebar: Psychiatry has unofficially used response to meds as an indicator of whether the illness is biological or merely a construct of the mind. Thus, borderline gets nowhere near the same respect as schizophrenia, which - ironically - evidences similarly low and perhaps even worse response rates.)

Dialectical behavioral therapy and other talking therapies produce beneficial results in the short term, but Drs Kernberg and Michels caution that "basic underlying chronic personality dispositions may remain unchanged."

Thus, years and decades after completion of therapy, individuals with borderline may still face major challenges in personal satisfaction with how their lives are going. On one hand, borderline has been dubbed the "good prognosis diagnosis," based on research showing an 80 percent remission rate over ten years. But the authors caution that these findings are focused more on DSM symptoms, "and much less on the subtle and permanent features of their difficulties in work, love, social life, and creativity."

The bad news is that despite the significant gains in our body of knowledge, "the relationships between clinical symptoms, deeper psychological structures, and underlying neurobiological systems are, as yet, to be explored."

The good news is we are learning as we go. As the authors conclude:

"Borderline patients have long been to psychiatry what psychiatry has been to medicine - a subject of public health significance that is underrecognized, undertreated, underfunded and stigmatized by the larger discipline. As with psychiatry and medicine, this is changing. New knowledge, new attitudes, and new resources promise new hope for persons with borderline personality."

Further reading from mcmanweb:

Borderline Personality Disorder

Those who live with individuals with borderline describe the experience as akin to walking on eggs. By contrast, Anne compared her dealings with people to "walking on shifting boards." The world is far from a safe place, and the ground beneath her could collapse any second.

"It’s like demons possess me," she related. Something inside of yourself so overwhelms you that you want to change it instantly. Such as slitting your wrists, impulsive sex, alcohol, and acting out. She described individuals with borderline as spontaneous and lively and loving until they get hurt. Then they screw up and fall apart. The irony, she said, is people with this disorder want to help so much, but the problem is they have trouble relating to people.

She emphasized that people with borderline can change (another speaker referred to the illness as "the good prognosis diagnosis"). Anne concluded with reference to her favorite bumper sticker, "Don’t believe everything you think."

Borderline Personality Disorder - Searching for Respect

In recognition of Borderline Personality Disorder Awareness Month, the second in a series:

Psychiatry has had one hell of a time trying to figure out borderline personality disorder, but we all know it when we see it. Case in point (from an article in this month's American Journal of Psychiatry):

"Ms A" told her therapist of an embarrassing episode in which she had shouted at a store clerk she perceived as rude. What set off the incident was the clerk would not accept her credit card.

Her therapist asked whether it was store policy not to accept credit cards or whether the clerk had singled out her credit card in particular.

"What difference does it make?" the patient responded in a fury. "Even if it was the policy of the store and not directed at me, he still should have been courteous!"

The patient then exploded into a screaming rage: "You’re not interested in empathizing with my feeling of being humiliated - only in figuring out how I caused the whole incident! It’s clear that you don’t care about me ... "

Yep, know it when we see it. Um - but what the hell is it?

As another article in the AJP (by leading expert John Gunderson MD of Harvard) makes clear, the very name borderline indicates various attempts at figuring out what the illness is NOT. In the words of outspoken critic Hagop Akiskal MD of UCSD, borderline over the decades has resembled "an adjective in search of a noun."

Back in the 1930s and into the 50s, it was thought that the noun had to be schizophrenia. According to the theory, it was believed that, in certain situations, some patients regressed into "borderline schizophrenia."

In the late 60s, those nouns became neurosis and psychosis. In a psychoanalytic framework, "borderline personality organization" occupied that nebulous middle ground between neurotic patients (who were considered treatable) and those who were written off as psychotics. "Neurotics who drive their shrinks crazy" would be another way to describe what clinicians observed in their offices.

Give psychoanalysis credit for bringing coherence to the phenomenon, including recognition of: emotional instability, need to attach to others, distorted sense of self and others, reliance on "splitting," and fears of abandonment.

From there, borderline progressed to a "syndrome," still within the purview of psychoanalysis. In 1980 - with the publication of the first modern DSM (DSM III), psychiatry formally recognized the diagnosis as "borderline personality disorder," but in the context of an endangered species consigned to a doomed habitat (Axis II).

Soon after, with the near-total collapse of psychoanalysis, borderline lost its chief group of champions, thereby leaving the diagnosis open to attack. Psychiatry's new generation of whizz kids reached for their chainsaws, along with the mandatory new noun. This time, the noun was depression, as in borderline being some kind of atypical depression.

But the diagnosis found support in new research that convincingly validated the illness, with a course that differed from schizophrenia and depression. Those with borderline showed clear signs of vulnerability to stress, but this - ironically - suggested yet another noun, PTSD (where there exists a substantial overlap).

The diagnosis entered the DSM-IV of 1994 virtually unchanged, though the question was raised about whether a patient could be considered borderline if he or she responded to meds. Against this backdrop emerged the hypothesis that borderline had to do with breakdowns in two key neurotransmitter systems, which translated to either: 1) difficulty in controlling impulses, or 2) emotional (affective) dysregulation.

Meanwhile (and predictably) bipolar became borderline's new candidate noun. Bipolar (with the new "bipolar II" diagnosis) was taking over territory formerly occupied by depression, and borderline was the next logical direction for expansion. But new studies pointed to critical distinctions between the two illnesses, including a failure in borderline patients to "mentalize," that is the capacity to relate to one's own mental states and the states of others.

Coincident with these findings was the success of the first therapy designed specifically for borderline patients, dialectical behavioral therapy. This brought on board a new generation of champions, which may have turned the tide in borderline's favor once and for all.

Still, as Dr Gunderson points out, for a highly prevalent, disabling, and deadly illness that virtually everyone these days acknowledges, borderline still has a long way to go before achieving respect. Psychiatrists receive virtually no training in the illness, few new investigators are entering the field, and proven treatments are often unavailable.

An upgrade to Axis I (in the company of bipolar, schizophrenia, etc) would be a step in the right direction. Says Dr Gunderson:

"It belongs on Axis I to signify its severity, its morbidity, and its unstable course. But it belongs there too to prioritize its usage and to underscore the need for its treatment to be reimbursed."

How about changing the name? Dr Gunderson kinda likes borderline, arguing that the term signifies the illness' "unclear boundaries while reminding us of an unwanted truth, namely, that psychiatric disorders, like other medical conditions, are heterogeneous and have flexible boundaries."

Me? I would go with "No-Noun Disease."

Further reading from mcmanweb:

Borderline Personality Disorder
Unexpectedly, the first borderline discussion there occurred during question time at a packed luncheon symposium on bipolar II. One of the presenters, Terence Ketter MD of Stanford, happened to say that as opposed to bipolar disorder, which is about MOOD lability (volatility), borderline personality disorder is about EMOTIONAL lability. As soon as they develop an emotion stabilizer (analogous to a mood stabilizer), he said, borderline personality disorder will become an Axis I disorder rather than Axis II.
Axis I disorders, as categorized by the DSM-IV, include bipolar disorder, depression, anxiety, schizophrenia, and other illnesses regarded as biologically-based and treatable with medications. Axis II disorders tend to get a lot less respect. As well as borderline personality disorder, these include antisocial personality disorder, narcissistic personality disorder, and a host of behaviors that impede personal and social function.
During the same round of questions, S Nassir Ghaemi MD of Emory University said that he thought borderline personality disorder was a "clinical condition" rather than a disease. As such, the condition is more appropriate for psychotherapy rather than medications treatment. Hagop Akiskal MD of the University of California, San Diego, was decidedly less accommodating: "I don’t have any use for the borderline diagnosis," he asserted.
Dr Akiskal, the leading proponent of the mood spectrum, has been badmouthing borderline for decades. A 1985 article he co-authored had this title: "Borderline: An Adjective in Search of a Noun." Dr Akiskal has made a study of personality, but in the context of temperaments distributed along a continuum ranging from benign to affective illness. ...

May is Borderline Personality Disorder Awareness Month

Yes, the heading is real, and it's about time. In April, 2008, in response to public advocacy efforts, the US House of Representatives unanimously passed House Resolution 1005 supporting the month of May as "Borderline Personality Disorder Awareness Month."

The resolution stated that "despite its prevalence, enormous public health costs, and the devastating toll it takes on individuals, families, and communities, [borderline personality disorder] only recently has begun to command the attention it requires."

I came across this nugget of information late last night while quickly scanning this month's American Journal of Psychiatry, where I was flabbergasted (a good sign) to find two editorials and three articles devoted to borderline.

Minutes before, I had been clicking through a PDF of the program book of the American Psychiatric Association's upcoming annual meeting which I will be attending in San Francisco in two weeks. The topic index to the program book lists 20 sessions devoted to mood disorders and 18 sessions devoted to personality disorders.

Knock me over with a feather. In the seven years I have been attending APA meetings, you would hardly know borderline and related illnesses fell under the purview of psychiatry. Three years earlier, with the intention of bringing myself up to speed on borderline, I found but three or four sessions on the program devoted to the illness. In fact - at a session on bipolar II at that particular meeting - two of the panelists and some of the audience questioned the validity of the borderline diagnosis in the first place.

A lot as changed since then. For starters, we know that the illness cannot be written off as mere bad behavior or as a variant of a mood disorder. Rather, it is abundantly clear that we are dealing with a serious medical illness that condemns four percent of the population to tortured lives, with suicide rates on a par with depression and bipolar.

Individuals with borderline face extreme difficulty responding to their environment, a process that science is showing to be mediated by the biology of the brain.

We also know that individuals with borderline respond well to certain types of talking therapy, and that their long term outcomes are exceptionally favorable. The only reason that meds work less well for those with borderline is because it is patently obvious we haven't come up with the right meds.

A very strong case can now be made - indeed, an undeniably airtight one - that the highest priority for the next DSM is to shift borderline personality disorder from Axis II - psychiatry's version of Siberia - to Axis I, in the same company as depression, bipolar, schizophrenia, and other illnesses the profession takes seriously.

NAMI has been successful in promoting public awareness for borderline while the NIMH has invested greater resources in research. In January this year, Time magazine devoted a feature article to the illness, and over the past two or three years we have witnessed a number of popular new books on the topic.

So, back to last night: In the space of ten minutes, from two different sources, I came up with undeniable evidence that psychiatry is finally starting to give borderline the respect it deserves. This is the result of incremental changes over a long period of time rather than an overnight sensation.

But - overnight - it suddenly occurred to me that this new professional respect, combined with public awareness, has to be one of the three most significant mental health events I've encountered since I began writing about my illness ten years ago, equal to the recognition of bipolar in young kids and to the mind-boggling advances in brain science.

The effect is bound to significantly improve the lives of countless individuals, long neglected and even held in contempt by professionals who should have known better. It is also likely to generate a backlash, particularly if people start perceiving borderline as a fad diagnosis.

So ...

I will pay a return visit to this months AJP for a long deep perusal, plus check out other sources, and will be reporting back in a series of blog posts this week. Stay tuned ...

Further reading from mcmanweb:

Borderline Personality Disorder

In true Axis I depression, Dr Paris explained, when patients come out of a depression, they are nice people again. Individuals with personality disorders, by contrast, can come out of a depression and still have problems with life. Unfortunately, clinicians prefer not to want to hear about personality. It means trouble. They would rather throw more meds at the problem.

The world is complicated, Dr Paris noted, but we want it simple, and therein lies the challenge: In the bipolar II symposium, the presenters were discussing difficult-to-treat depressions. The depressions they were talking about were those that acted suspiciously like bipolar, which strongly implies using mood stabilizers instead of antidepressants.

Dr Paris was also talking about difficult-to-treat depressions, but the ones he described pointed to personality issues and a long course in talking therapy. These patients are not going to get better fast, he warned. Clinicians have to plan for chronicity. Moreover, in a true personality disorder, the course of the illness is different. These individuals are not going to become bipolar over time. ...

Mozart, Genius, and Practice-Practice-Practice

Consider Mozart, who wrote his first symphony in utero and performed in his own rock opera at age five months, changing his own diapers (admittedly with mixed results) between acts. Clearly this is genius personified.

Not so fast, writes NY Times columnist David Brooks. Those early compositions of his were strictly kid stuff, and his performing skills as a child prodigy are highly over-rated. The Mozart you encounter in concert and opera halls is the product of an adult mind honed to a fine creative edge through years and years of unstinting effort.

Writes Brooks:

“What Mozart had, we now believe, was the same thing Tiger Woods had - the ability to focus for long periods of time and a father intent on improving his skills.”

Rather than some mystical divine spark or high IQ, genius may be as mundane as practice-practice-practice. Citing two new books - “The Talent Code” by Daniel Coyle and “Talent is Overrated” by Geoff Colvin - Brooks says it helps to have some kind of adult role model as a kid, say a novelist living in your town. Then you might dare imagine yourself writing your own masterwork. Armed with this ambition, you would start reading novels and literary biographies and thus attain a core knowledge of the field.

Mind you, it doesn't hurt if you have a bit more going for you than Lennie in "Of Mouse and Men."

Anyway, here you are - somewhere north of Lennie and south of Einstein - slowly building up your body of knowledge. Next thing, you're engaging in the intellectual equivalent of playing with your food, moving ideas around, divining patterns (excellent for the memory), and otherwise thinking like a novelist.

Then practice-practice-practice until your mind turns labored conscious skills into effortless unconscious ones. But the mind is sloppy, Brooks advises, and tends to settle for good enough. So, you practice your routines slowly. You break down your efforts into tiny parts and repeat-repeat-repeat until the brain internalizes a better pattern of performance.

At the right time, a mentor steps in who provides feedback, corrects your tiniest errors, and pushes you to tougher challenges. By now, your brain is programmed to understand and solve future problems.

According to Brooks, the primary trait is not genius. Rather, “it is the ability to develop a deliberate, strenuous and boring practice routine.” The hard wiring of our genes plays a part, but Brooks concludes, “the brain is also phenomenally plastic. We construct ourselves through behavior. As Coyle observes, it’s not who you are, it’s what you do.”

So back to Mozart. According to critics, as reported in Wikipedia, Mozart composed his "breakthrough work," his Ninth Piano Concerto, when he was 21. The concerto has been assigned a "Kochel listing" of 271, which implies a vast body of work that fell short before the composer hit his stride. Practice-practice-practice.

But for Mozart, good enough was not good enough. After forming a friendship with Franz Joseph Haydn and developing an appreciation for the Baroque masters, Mozart did the equivalent of changing his golf swing, which set the stage for the transcendent pieces by which we know him best.

"The Marriage of Figaro", "Jupiter Symphony", and his "Requiem" - among many others - are the work of a man in his thirties.

In short, geniuses are made, not born. Or are they? Certainly others have labored as long and hard as Mozart only to become industrious drudges lacking that - ahem - divine spark. Think Salieri.

So why don't we forget about outcome - we can't control whether we will end up geniuses or not. But we can control process - the art of constantly challenging and reinventing ourselves through practice-practice-practice. Do we have it in us to become Mozart? Who knows? Can we fashion our modest talents into something more formidable? Chances are you're doing it right now.

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.