Spitzer and the DSM - Part IV

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

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

- Ecclesiastes 2:11

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

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

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

And again:

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

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

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

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

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

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

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

To be continued ...

Robert Spitzer and the DSM - Part III

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Then he rose from his chair and was gone.

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

Rerun - Is Bipolar Cool?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Brief History of Mental Illness

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

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

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

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

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

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

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

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

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

Age Seven with Schizophrenia

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

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

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

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

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

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

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

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

In my original blog piece, I concluded:

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


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

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

Robert Spitzer and the DSM - Part II

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To be continued ...

Robert Spitzer and the DSM - Part I

Psychiatrists appreciate a free meal as much as I do, which may explain why dinner symposia sponsored by various pharmaceutical companies used to the most popular events at APA annual meetings. I cannot recall what the topic was at this particular symposium at the 2003 APA in San Francisco, nor who the speakers were, but I can never forget who grabbed the empty seat next to me. “Robert Spitzer,” read his name tag.

Robert Spitzer (pictured here) is by far the most influential psychiatrist you never heard of, the man responsible for the ground-breaking DSM-III (diagnostic Bible) of 1980. It was Robert Spitzer who banged the final nail into Freud’s coffin and led psychiatry into the modern era. Until then, believe it or not, psychiatry had no practical system for distinguishing anxiety from depression, from bipolar disorder, from schizophrenia, from people who are assholes.

The first DSM, from 1952, naively attempted to separate out conditions with an obvious biological basis (such as “acute brain syndrome associated with intracranial infection”) from those for which it assumed came from a maladaptation of the individual to his or her environment. This later category included schizophrenia, which it labeled as “schizophrenic reaction.”

According to the DSM-I, these reactions (psychotic, neurotic, behavioral) “are as much determined by inherent personality patterns, the social setting, and the stresses of interpersonal relations as by the precipitating organic impairment.”

Under this way of looking at behavior, symptoms were less important than whatever psychosis, neurosis, or behavioral quirk was supposed to be lurking beneath the surface. Indeed, only a token effort was made to differentiate the likes of “schizophrenic reaction” from “manic-depressive reaction,” both which were seen as “psychotic disorders.”

Psychosis was Freud’s prognosis for hopeless. Psychiatry virtually turned its back on these individuals, but not before blaming them and their parents for failing to adjust.

Depression, in the meantime, was viewed as part of “manic-depressive reaction, depressive type” or a “depressive reaction” under the heading of “psychoneurotic disorders.” Neurosis was the Freudian grand organizing principle to explain the walking wounded, viewed as psychiatry’s meal ticket. According to the DSM-I, “anxiety” was the driving force of neurosis, which may “be directly felt or expressed” or be “unconsciously and automatically controlled” by various defense mechanisms, such as depression.

That’s right. Depression was a “reaction” to anxiety, er, neurosis.

We’re not done. Depression could also be viewed as an expression of personality, as in “cyclothymic personality disorder.” The DSM-I saw personality disorders as a “lifelong pattern of action or behavior” rather than “mental or emotional symptoms.” These individuals were not exactly hopeless write-offs, but any psychiatrist who took them on as patients was regarded as a “hero.”

In the final analysis, none of this mattered. Whether written off as hopeless or viewed as a meal ticket, for all practical purposes the only effective treatment of the day was time. The only catch was that the time cure typically took years to accomplish.

The DSM-II of 1968 was largely a rerun of the DSM-I. Its biggest change was upgrading schizophrenia and manic-depression from adjectives modifying “reaction” to full-blown nouns. At this rate, psychiatry was ready to be dragged kicking and screaming into the twentieth century by the year 3014.

But even then, reform was in the air. By now, the first generation of psychiatric meds was on the market, along with new forms of talking therapy. Clinicians needed a rough guide to work with, along with a practical means of communicating with other clinicians and interested parties.

In the meantime, psychiatry was being subjected to attack from a variety of fronts, including a strong antipsychiatry/civil liberties movement rebelling against forced institutionalization and other abuses, an insurance industry questioning spending good money on unproven long-term talking therapies, and reform-minded psychiatrists fed up with the anti-science mindset of Freud’s followers.

On top of that, institutions were being emptied out. People with serious mental illness were suddenly on the streets. Psychiatry could either get involved or choose to keep milking its rich neurotic clientele, a business it was rapidly losing to budget-conscious psychologists and social workers.

In 1974, Robert Spitzer of Columbia University drew the assignment of overseeing the DSM-III, with the ostensibly narrow brief of harmonizing the DSM with international standards, but little did they know ...

Now, here he was seated next to me, and here I was looking up from my salad trying to think of something to say.

To be continued ...

My Friday Night

You are looking at 250 people eating dinner. The event is the annual NAMI San Diego Inspirational Awards Dinner, held last Friday. I’m on the NAMI SD board and was part of the committee that planned the dinner, so the sight of an ass on every available seat in the room positively warmed the cockles of my heart.

NAMI SD - through the support of its volunteers, the efforts of a very hard-working staff, and in partnership with numerous providers and organizations throughout San Diego County - runs an ambitious schedule of support, education, advocacy, and mental health services. Both the dinner and the annual walk serve to get out our message, connect with our community, and to raise funds.

I joined the NAMI SD board in May. The dinner was one of the items on the agenda, and I made the rookie mistake of opening my mouth. I happened to mention that I had attended two national NAMI dinners. Next thing, I was pressed into service for the dinner committee.

Trust me, every board meeting after that, I have breathed through my nose.

My major contribution to the dinner was setting up three new awards: A Media Award, a Research Award, and an Employer Champion Award.

The media at its best acts as our social conscience. Here I am, pictured with David Rolland, editor of the alternative weekly, CityBeat, that features a combination of edgy reporting and local scene reviews aimed at a young hip audience. Your average NAMI member - typically burdened with caring for a son or daughter with serious mental illness - probably doesn’t have the latest CityBeat folded open on the coffee table to the latest event listings.

But just two days before the dinner, CityBeat ran this story by Kelly Davis: “One person's trash - Homeless citizens argue that police, city destroy their stuff.”

For more than a full year, CityBeat got in readers’ faces with stories that featured providing a human face to homelessness. All through 2008, week after inexorable week, with the same unrelenting nature of the ghost of Banquo appearing to Macbeth, new faces with new narratives made their presence felt.

The world of CityBeat and the world of NAMI came together. Coming up with a winner was a no-brainer. Significantly, in presenting the Media Award, rising political star Councilman Todd Gloria noted that CityBeat accomplishes more publishing once a week than other publications (we won’t mention names) do publishing every day.

An issue dear to my heart is research. For years, I have attended psychiatric conferences throughout the country (and one in Scotland) where I have had the pleasure of witnessing some of the smartest people in the world turning in their science projects, many of them from San Diego (with a research community second to none).

These are people who have dedicated their lives to improving ours. The ones on our short list had received the highest international honors from their peers. But I strongly felt that we - the ultimate beneficiaries of their efforts - should show our appreciation, and so did our board and dinner committee.

David Braff MD (pictured here) has devoted his life to schizophrenia, and in the process has revolutionized psychiatric, genetic, and brain research. As one example, Dr Braff has pioneered “endophenotype.” This approach allows researchers to investigate an outward feature (phenotype) such as psychosis by looking at underlying phenomena, such as the inability of the brain to filter out sensory stimuli.

NAMI was founded by parents of individuals with schizophrenia. I have listened to their stories and been greatly moved by their love and compassion and dedication. Back in the bad old days, these moms and dads were blamed for being bad parents. Even today, they encounter a system that seems to frustrate them at every turn. Without the proof and truth provided by research, the ignorance and stigma surrounding mental illness would be a lot worse and everyones’ futures a lot more bleak.

We may not comprehend the fine points of brain science, but we are in profound awe of the efforts of its practitioners, and on Friday night we were all very happy to demonstrate our appreciation.

It goes without saying that without opportunities in the workplace, recovery simply does not happen. Friday was our chance to say it. Bettie Reinhardt, our executive director, has had very good experiences working with Alex Boyce and Jeff Hendricks, who labor as managers on the coal face for retailers TJ Maxx. TJ Maxx has an enlightened policy worldwide for hiring individuals with special needs, including those with mental illness.

Our intention had been to present our Employer Champion Award to the corporation, but Bettie came up with the brilliant idea of personalizing the Award by singling out Alex and Jeff. So, instead of a corporate suit turning up to collect the award, we had two heroes who were glad to be there. Alex and Jeff are two unassuming individuals with an unflinching dedication to doing the right thing. Going the extra mile for others requires tremendous moral courage, and NAMI SD was delighted to show its gratitude.

In their acceptance remarks, each of these awardees made a special connection to the audience. When they spoke, the dinner plates and utensils at the tables literally stopped clattering. Trust me, it was a very gratifying moment for me to have played a part in making this happen.

There was a lot more to the dinner: Elyn Saks, author of “The Center Cannot Hold,” received the Inspirational Person of the Year Award and rocked the house with a moving address. Helen Bergen received a Lifetime Achievement award for her legendary dedication to NAMI SD, and the very personable Devin Eshelman the Young Advocate Award. In addition, NAMI SD debuted its own 15-minute video, “Five Faces of Hope.”

Add to that a raffle and a silent auction, plus the million and one details that can spell the difference between success and disaster. Everything went off without a hitch; the evening was a brilliant success.

Here’s a picture of my grandchild, Edward Stewart, a few days old. I received this from my daughter on my iPhone as I was unwinding over a beer with three good friends. What a way to close the evening.

Things such as serving on dinner committees take me way outside my comfort zone, which is one of the reasons I became involved with NAMI SD. It’s very easy, working from home, for me to get stuck in my own rut or lose touch with why I am here. Contact with real people, even if the topic is floral arrangements for the dinner, is my reality check.

Here I was, engaging with ten or more individuals bringing a full range of life experience to the table. I listened, I learned, I connected. Next year, when they’re putting together a new dinner committee, I will have no hesitation in volunteering. But I will put my foot down: Dandelions (Norwegian dandelions) for floral arrangements - I won't take no for an answer.

My Life as an International Awardee - Conclusion

In the first piece to this series, I recalled my shock and dismay over being informed that I was to receive the Mogens Schou Award for Public Service, a major international award. In the second installment, I related how hearing Nobel Laureate John Nash at the 2007 APA in San Diego helped me understand the importance of what a little bit of recognition can do for one's recovery. To pick up where I left off ...

Three weeks following the APA, I was off to Pittsburgh for the Seventh International Conference on Bipolar Disorder to collect my Award. I knew I would be overexcited - hypomanic in a bipolar context - and as a precaution I arranged to have a platonic conference date to act as my frontal lobes.

The conference organizers comped me with a hotel suite (a suite!) that had real towels, plus a view out the windows. To contrast with the first conference I attended in 2001, back then I had a Priceline deal at a hotel a good long walk away from the venue.

I recall back in 2001 registering and helping myself to coffee and Danish, plus a yogurt and a juice, while trying to juggle my conference materials as I sat myself in a cramped space and attempted to make small talk with a very attractive European pharmacy expert. The Joe Cool act didn't fly. My coffee was slopping over the rim of my saucer, and the only way I would be able to negotiate my Danish was if my elbow were to suddenly sprout fingers.

Nevertheless, I managed to get through the day without totally embarrassing myself.

On the evening of Day Two of that conference I made my first minor faux pas (that is to say, the first one that I noticed). I hadn't bothered to take my sport jacket to the second day of the meeting. But now we were being shuttled off to a more formal setting at the Carnegie Museum, and I couldn’t exactly go up the elevator to retrieve my jacket.

I was definitely out of place as I gamely introduced myself to Michael Thase MD, one of the Conference organizers. A roving photographer asked a group of us to pose. Me, Dr Thase, and a darkly-tanned blond Dutch pediatric psychiatrist in open-toed stilettos. I so totally did not belong in this picture.

The occasion was the first-ever presentation of the Mogens Schou Awards and dinner, where I managed not to further embarrass myself. Later, the shuttle dropped us off at the conference venue, and I set off on my own into the night, back to my hotel.

Fast Forward, June 2007: The second evening of the conference was once again reserved for the Mogens Schou Awards and dinner, once more held at the Carnegie Museum. This time, I showed up dressed to kill, in a black business suit and a Thomas Pink shirt that probably threw me back for far more than my suit.

The cocktail hour portion of the evening was coming to a close. It was time for me to move forward toward a small stage platform and hover. On a small table were four Plexiglas Awards, resplendently bathed in discreet overhead lighting.

David Kupfer MD, head of the psych department at UPitt, issued some opening remarks and handed over the first Award of the night - Education and Advocacy - to Adriano Camargo, president of the Brazilian Association for Affective Disorders. Ellen Frank PhD of UPitt and a pioneer in a certain type of talking therapy for bipolar - then presented two Awards to the University of Barcelona powerhouse research team of Francesc Colom PsyD, PhD and Eduard Vieta MD, PhD. There was one Award remaining on the table.

Michael Thase approached the podium, with the Public Service Award in his hand. "I'm pleased tonight," he began, "to show our gratitude for the man who is my favorite person in medical journalism ..."

SuddenIy I was on the podium, shaking hands with Dr Thase. Then I had the Award crooked in my arm. The applause died down. It was my turn to speak.

I could have told these people what it was like for me back in 2001. But no one had to know that. This was my moment, my time. I belonged in this picture.

But life has a way of intervening. The next day, a certain psychic undertow began to kick in. I woke up much later than usual and spent the last day of the conference in a sort of anti-climatic semi-coma. By the time I flew out the next day, I felt a cold coming on. Back on my mountain, my mood dropped like a manhole cover. My batteries were dead. No energy. I needed to hibernate.

None of this Award going to my head business for me. My brain and my immune system have a way of keeping me in my place. Before enlightenment - draw water, chop wood. After enlightenment - draw water, chop wood.

I found it gratifying that I was not exactly the same person drawing water and chopping wood, but the positive strides I was making in moving my life forward had blinded me to the fact that I was pushing myself way too hard. That plus the fact the last two or three years of my life were catching up with me. Too many life-changing events compressed into way too short a period of time with nothing but factory-reject vulnerability genes to handle the load.

Curse you, 5HHT polymorphism!

My Life as an International Awardee - Part II

In a recent blog piece, I brought up the shock and dismay I experienced more than two years ago over being singled out for a major international award, named in honor of a legend who revolutionized psychiatry. But I also noted the hard work I had put in to merit such an honor, in the first place. To continue:

At a convocation lecture delivered by John Nash at the 2007 APA 40 miles down the road in San Diego, I got an unexpected insight into what something like a Mogens Schou Award can do for your recovery. John Nash (pictured here) is the mathematician who shared the 1994 Nobel Prize in Economics, upon whose life the book and movie, "A Beautiful Mind," is based. A good case can be made that whatever drove Dr Nash to experience paranoid delusions initially allowed him to make the kind of novel connections upon which ground-breaking mathematical theorems are based.

Schizophrenia rarely just descends full force on an individual. Years of eccentric and erratic and sometimes brilliant behavior tend to precede the definitive break. Various recovery advocates like to point out that Dr Nash’s schizophrenia remitted naturally, without meds. That may be true, but Dr Nash in his Nobel autobiography acknowledges he lost 25 years of his life to his delusions.

Nevertheless, in his talk to the APA, Dr Nash raised the possibility of an adaptive advantage to schizophrenia, with his own games theory twist. I’m presuming he was referring to schizophrenia in its more benign manifestation, what the experts refer to as the prodromal phase, that quirky quiet time before the entire brain tragically implodes and robs its owner of the gift of rational thought. Or perhaps a form of “schizophrenia lite,” what psychiatrists call schizotypal personality disorder, characterized by oddball thinking and weird social behavior without the delusional psychosis.

Indeed, at the same conference, I heard prominent psychiatrist Nancy Andreassen MD, PhD of the University of Iowa advance a similar thesis. Newton, she said, entertained unusual beliefs and had a psychotic break later in life. The eccentric Einstein had a son with schizophrenia in his family and displayed schizotypal traits. James Watson (of Watson and Crick fame) also had a son with schizophrenia.

"So we can say that three of the most important discoveries in modern science were done by men who had association with schizophrenia," Dr Andreasen pointed out. "What’s the odds that occurred by chance? There must be something there."

It turned out that Dr Andreassen’s research uncovered a far more obvious connection to creativity - namely bipolar. Still, the general thesis is valid. Our brains don’t have the same filters as normal brains. Too much stuff coming in, what the experts refer to as “low latent inhibition.” We have trouble tuning things out - thoughts, feelings, senses. Our in-trays are always overflowing, frequently overwhelming.

Meanwhile, our neurons don’t communicate in the same predictable patterns. We make novel connections. At the time of her talk, Dr Andreassen was investigating an area of the brain called the association cortices. If I understand Dr Andeassen correctly (and also taking into account latent inhibition), in a creative mind the association cortices can pull the background noise of a refrigerator (which most people manage to ignore) from one part of the brain, an unpleasant childhood memory (which most people have long ago put to rest) from another, a weird observation about Hannibal and his elephants from yet another (what is it with my obsession about Hannibal?), a reptilian urge to throw Richard Simmons off a cruise ship and into a school of sharks who are slow picky eaters (now you are relating), and come up with the grand unified theory of everything, which is kind of my mission in life, along with “enjoy the peanut butter.”

The catch is one needs what they call strong “executive function” to keep track of this crazy internal dialogue and take charge. Think of the “I” in the control room. When you respond with “but roosters don’t lay eggs” to a classic brain-teaser, you can give this little guy all the credit.

But when the “I” fails - typically in response to too much happening at once - bad things happen. No one is home, no one is in charge. Thoughts and feelings and senses inerrantly find their way of disorganizing into chaos.

Maybe the outcome is a panic attack, perhaps a psychotic break or a manic episode or explosive anger. Another way of looking at it is the brain is finding its own way of taking refuge. The frontal lobes may even shut down, which is how a lot of people view their depressions. Or the entire operating system may refuse to boot up, which is one way of looking at autism.

Sylvia Nassar’s terrific book, “A Beautiful Mind,” serves up John Nash as a classic case study of all that can go right and all that can go wrong in the brain. Dr Nash's great creative work was done in his early-mid twenties, before his illness manifested in full. But Nassar’s account gives us the unmistakable impression that this particular beautiful mind was always a case of schizophrenia waiting to happen. From Day One, he was an outsider, an outlander from West Virginia with a weird way of looking at the world and a noticeable deficit in social skills. Even in a profession notorious for its oddballs and cranks, John Nash never quite fit in.

In short, a man with no ordinary brain, understood by few. Thoughts connected in startlingly original ways. On one hand, it produced a stunning piece of rationality - games theory - that was so novel that his contemporaries failed to fully grasp its significance. On the other, this same remarkable brain morphed into astonishing irrationality - he actually thought he was the king of Antarctica - a tragedy that robbed its owner of a quarter century of his life.

And here he was, at the podium at the APA, trying to explain this strange phenomenon of a thinking machine of nearly limitless dimensions spewing out gibberish. Figure out a law of nature that governs such an occurrence and you will get a branch of science named after you, guaranteed, or a religion - take your pick.

Dr Nash was talking to the right people, people profoundly interested in the mysteries of the human psyche, but - like me - they found his message terribly difficult to comprehend. It didn’t help that Dr Nash was reading in a monotone off a densely-typed, jargon-laden script held very close to his face. One minute into the talk and I was looking this way and that way into a sea of glazed eyes. Some of the attendees began discreetly ducking out, and I considered doing the same. Then I reconsidered. You don’t walk out on a Nobel Laureate, I decided. (Donald Trump, yes, and I would make sure to knock over a chair on the way out, stupid asshole.)

Suddenly, Dr Nash started talking about his return to sanity and my ears pricked up. Significantly, he mentioned that his recovery began when his reputation finally started catching up with the acclaim he felt he deserved.

Now I could relate - me Mr 400 Math SAT, him Dr Uber Equations. It turns out on one level at least, the two of us had a lot in common. Say what you want, recognition counts. Whether from a Nobel committee or the top bipolar experts in the world, or for that matter the local bowling league, it’s sure nice to get a pat on the back.

We toil mightily, nameless nobodies never anticipating so much as a simple thank you. Too often, we put up with thoughtless behavior and abuse. Too often, we have nothing to show for our labor, held in contempt, written off as not like everyone else. But we persist, either because we’re driven to do so or because it’s the right thing to do. We take our small comforts where we can find them - a handshake, a compliment from afar, a small act of kindness.

But our lot is that of an outsider. Just ask that skinny kid afraid to get on the school bus. Then - one day - the bus door opens and there’s a whole seat to yourself near the front. That cute redhead you kind of have a crush on breaks off a piece of jelly donut for you. The cool tough guy in the leather jacket with the duck’s ass haircut strolls from his throne in the back, claps a hand on your shoulder, and lets you know there is always a place in his circle for short nerdy kids with glasses.

You try to make a coherent reply by way of a lame joke, and the whole bus breaks out in appreciative laughter. Some idiot tries to rain on your parade, and you respond with, “Eat it raw,” like you know what it means. The bus driver shoots you a questioning look, but you just grin, as if to say, don’t worry, I’ve got it covered.

You now have everyone’s attention. “Listen up, guys,” you shout down the aisle, voice brimming with confidence. “Hannibal never won a battle with his elephants.”

Shit! Why can’t I just keep my big mouth shut?

To be continued ...