Flipping the script on psychiatry

 kw: book reviews, nonfiction, psychiatry, mental illness, bipolar, recovery, twelve step programs

After reading Unshrunk: A Story of Psychiatric Treatment Resistance by Laura Delano, I became even more thankful that I escaped the depths of psychiatric treatment. Psychiatry is a black hole; getting in is easy, while getting out is usually impossible. Let me settle two pieces of business before going further.

First, a piece of extremely serious advice: If you are feeling depressed and you seek the help of a medical or psychiatric professional, do not ever loosely say you have been thinking of suicide. To be clear, if suicidal thinking dominates your thinking all day, every day, and has done so for as long as you can remember, then it is worth telling this to a professional. Otherwise, beware: if a psychologist or psychiatrist becomes convinced that you are likely to harm or kill yourself, they are required to commit you to psychiatric care in a mental hospital. That's one way of dropping straight into the black hole. If you have no trusted friend or family member, contact the Inner Compass Initiative, founded by Laura Delano. Something to ponder: psychiatrists are people, with the same foibles as all of us. Many of them got into psychiatry because they wanted to find out why they had certain experiences (see image following!).

Second, a very brief mental history of myself. I was diagnosed with "Bipolar II Disorder" at age 54. In retrospect, it made certain old stories make sense. During my K-12 years, I would occasionally "flip out". Otherwise I was a quiet kid, sometimes bullied but too big for the bullies to feel safe going too far. The school I attended in grades 4-6 had an abandoned chimney, the ruins of a demolished house, at the back of the property. One day in 5th grade I led a group of kids to "Play Santa Claus" by climbing down the chimney. We returned to class covered in soot. On a few other occasions I was overcome by a burst of energy and spent the lunch period running through a stand of Sumac, holding a branch and whacking the plants. During the high school years I became the family's firewood chopper and splitter. This continued into college; it is a great way to blow off steam. During my first year at college, on two occasions I was overwhelmed by overwork—I tend to take on more work than I am capable of completing—and wound up in the school clinic under sedation. As an adult I wondered how I could be so moody, so unpredictable, but only for short periods at long intervals. I distinctly remember reading an article that quoted several creative people who discussed their swinging moods (at that time the usual term was "Manic-Depressive"); one writer expressed it this way, "When I am up, I write, and when I am down, I edit." I sat back and thought, "Oh, neither mood swing is essentially bad because both can be useful." At age 53 I made a new friend. He told of spending 10 years taking Zoloft, but being concerned that it wasn't working well any more to control his experiences of major depression. He also told of sometimes spending three days obsessively cleaning his apartment, or seven hours washing a car. I said, "That sounds manic (by this time I knew a little about Bipolar "disorder"). Why don't you mention these things to your shrink the next time you see her?" He did so and was switched from Zoloft to one of the anticonvulsive drugs that are useful in mediating Bipolar mood swings. He was re-diagnosed as Bipolar I (stay tuned). The next time I had a depressive period of my own, that had come on without reason, I spoke to my doctor about it. He prescribed a low dose of Zoloft. At the follow-up appointment a month later, I was high as a kite. He said, "OK, this is mania. Let's try something different." Zoloft is an upper, not a mediator. I don't recall which drug was used. It was apparently helpful, but I began to need a daily nap and I gained some weight. I went to see a psychiatrist, one of only two that I consider competent, named Valentine. She explained more, saying that I seemed to be between Bipolar II and Cyclothymia, and suggested using half the dose of the medication. Six months later, I found that she had moved out of state. There followed a period of yearly visits with four different psychiatrists, all "bottom of the barrel"; I could tell they were crazy, and had got into psychiatry mainly to figure out their own issues...and failed. One of them wanted me to switch my medication to Depakote. I said, "I know someone who takes that. He gained 90 pounds. I already feel bad about being a little overweight. How will this keep me from getting suicidally depressed?" I stormed out and didn't pay the bill when it came. Finally I got another competent psychiatrist, who switched me to Abilify, a low dose, saying, "This will keep depression from going too deep, and allow you to have a little 'fun' when you're manic." I deduced that it was a milder form of Zoloft. It worked quite well, but I still needed a daily nap, and continued to gain weight. Then one day, going to a scheduled appointment, I found his office locked and dark, and nobody in the building knew what happened to him. I had wanted to discuss with him how I could stop the meds completely. I had been taken by a friend to get acquainted with a man who had a severe case of Bipolar I, but had weaned himself off all medications, with his wife's help. Rather than try to find another doctor, I decided, "I'm done with this." I had another month's supply of Abilify. I cut the pills in half and took a half dose for a month, then cut the remaining half-pieces in half and used them up over the next two months. In the meantime, I consciously practiced awareness of my mood. Like the writer, I have things I can do when I am "up", which I call "open", and other things I can do when I am "down", which I call "closed" or "reserved". Now I am 78, off meds for more than 15 years. My wife, who has put up with me just over 50 years, is more relaxed: I am more stable. I thank God I was never institutionalized, and never put on a 4- or 5-drug cocktail. Such regimens are an admission of failure to find an effective treatment.

Now to the book. Ms Delano is apparently prone to overreaction to emotional stimuli. It is common for a young girl to one day look in the mirror and think, "Who is that? Who am I?" In her case, at age 13, it seems to have led to a panic attack, or something very like one. She became edgy and uncooperative at home, and after some time her mother took her to see a psychiatrist. She got a diagnosis (Bipolar) and a medication. That was the entry gate to fourteen years of increasing misery, including a few periods in mental facilities, yet she managed to complete a degree at Harvard. At one point she committed suicide but was rescued.

Along the way she was given various diagnoses—Bipolar wasn't mentioned after the first year—culminating in Borderline Personality Disorder with Treatment Resistance. Those six words really mean, "We don't know what the Hell is going on, she's just impossible to handle." This exposes the darkest part of the underbelly of psychiatry. You can't get away with stopping a psychotropic drug instantly. It is like a heroin addict stopping "cold turkey". Withdrawal symptoms are dreadful, and can kill. I experienced a little of that the few times a drug was switched for me. She had it in spades! When a doctor recommends "tapering off" a drug, they typically recommend a two- to four-week taper. That's too fast. Half a year to a year is better, and in the case of Lithium, it may take several years to wean your body from lithium toxicity. Remember this principle: withdrawal symptoms are very similar to the condition being treated. This does not mean relapse. It means the tapering needs to be more gradual.

Side note: I have read a few times that "the therapeutic window for lithium is narrow," which means that the amount that helps is only a little less than the amount that harms. Actually, that window is negative: The "help" that lithium affords is actually a side effect of lithium toxicity. Lithium "helps" by damaging your nervous system, reducing a harmful syndrome by reducing everything! This is compounded by growing lithium dependence, which takes years to shake. See the "Tapering" section of Inner Compass for more information.

Chapter 34, "Critical Thinking", deserves special mention. It outlines the sad circumstance that psychiatry has become big business. The largest proportion of political lobbying (bribery) is by the pharmaceutical industry. Doctors of all kinds, not just shrinks, are aggressively pushed (sometimes coerced) to push pills at every juncture. Analyzing the DSM (Diagnostic and Statistical Manual, the "psychiatrist's Bible"), the author finds that many of the items listed share more with fads than with facts. Assertions without appropriate evidence, and suppositions without logical reasoning. Maybe you've heard that "chronic depression is an imbalance in brain chemistry." Would it surprise you to learn that no such imbalance has ever been measured? Never, in spite of much trying.

A word about tapering. Drugs are dispensed in sizes of 1,2,4 or ½,¼, etc. If the basic dose is 10 mg, and you're on 40 mg, there's no 30 mg to taper to. And you may need to reduce from 40 to 35 for a week or two, then 30, and then 27, 25, 23, and so forth. What can you do? I suggest pill splitting. My wife takes a statin drug for cholesterol. But she doesn't need much. The smallest available dose is 10 mg. She splits it to 5. For a while she cut the pills into 3 pieces, but that wasn't quite enough. So if you need to go from 40 to 35, what do you do? Have the doctor (it might take a lot of negotiation) prescribe 20's and 10's and 5's. 20+10+5=35. Next reduction, 20+10=30. Then split a 5, so 20+5+2½ = 27.5, and so forth. You get my point.

I'll leave it to you to read this book. If you have any kind of "personality disorder", or know someone who has, get it and read it. Me Delano's Odyssey out of the sloughs of psychiatry is epic. Truly Epic. She is "unshrunk" now, and much happier for it. I also am happier, having escaped the clutches of a system that "disorders" everything.

So get the book!

----------------------------

A little glossary:

• Syndrome: A collection of signs and symptoms that occur together and characterize a specific condition. 
• Disorder: A disruption or impairment of normal bodily functions or mental processes.
• Bipolar I Disorder: Characterized by manic episodes, which are periods of abnormally elevated mood, energy, and activity levels. Individuals may also experience major depressive episodes. 
• Bipolar II Disorder: Involves hypomanic episodes, which are milder forms of mania, and major depressive episodes. Individuals do not experience full-blown manic episodes. 
• Cyclothymic Disorder: A chronic condition characterized by numerous periods of hypomania and mild depressive symptoms that do not meet the full criteria for Bipolar I or II. Also known as Bipolar III.

Note that a syndrome describes a condition, which may be a disorder, but not always. The condition of physical fitness, which includes strength, vitality, and energy, can be considered a syndrome. It is in no way a disorder. The key term about disorder is "disruption or impairment".

I would prefer that the three levels of Bipolar be called "syndromes" rather than "disorders." In my case, with appropriate understanding and practice, Bipolar II is a condition that I can take advantage of to experience a broader range of social interaction. Furthermore, I consider bipolar syndromes, regardless of severity, as exaggerations of the normal mood cycling that is inherent in the human condition. A doctor friend of mine (definitely not a psychiatrist; he's to sane to be one) explained it this way: 

The scale of moods runs from zero to ten, from the lowest possible to the highest possible. Most people rock along in the 4-6 range, where 5 is "contented, neither sad nor excitedly happy". After a very fortunate event, such as a promotion, a marriage proposal or acceptance, or reaching a tough goal, we feel extra happy, even excited, getting into the range of 7 or 8 for a while. This can't be sustained for long, and we settle back to a 6, and then a 5. After a very unfortunate even, such as being fired, or the death of someone close to us, we feel very low, even depressed, in the range 2-3. Death of a parent, child, sibling or spouse causes us to experience grief, a solid 2 or even 1, for about a year. But this eases over time and we resume our usual "setting" near 5. A depressive person has a chronic setting near 2 or 3. A maniac is stuck at 7 or 8. Normal mood swings run between 3 and 7, though most of the time the 4-6 range is "home base". Bipolar II and Cyclothymia swing between 2 and 8, while Bipolar 1 ranges between 1 and 9. Hitting zero leads reliably to suicidal thinking and often a suicide attempt. Hitting 10 leads to both internal distress and social ostracization for being "too crazy". Extreme Bipolar I bangs these limits on a regular basis and probably does need medication.

There is also the matter of cycling frequency. Normal mood cycles last 3-12 months. Having a "blue mood" each winter is a sign of a 12-month cycle, emphasized or even triggered by seasonal changes. Rapid cycling is three months or less. I am a rapid cycler, which is common for Bipolar II. I have 4-8 depressive (or "quiet and reclusive") episodes yearly, and shorter periods of hypomanic mood (on the edge and extra social) in between. If I am in a quiet phase but must perform a social task such as giving a speech, I can do so, but I "pay the price" with the need to "hide out" for a number of days thereafter. When I am on an even keel or even hypomanic, giving a speech is no problem; it is a pleasure. I just have to keep myself in check when I am up; I tend to interrupt myself or lose track of a train of thought.

Perhaps all this is foreign to you. You may be solidly sane. I am so glad for that! If any of this rings a bell, recognize that you are still most likely close to normal, perhaps just "a little more than normal." Gravitate to friends or family who give you space without judgment. Be wary of psychiatry, but don't write it totally off. Sometimes it's needed. Just don't give up your autonomy to a shrink.

The anti-shrink case

kw: book reviews, nonfiction, psychiatry, history, polemics

In my prior review, of a book about psychiatry written by psychiatrists, I wrote (perhaps more than I should have) of my experience with psychiatrists. To sum up my takeaway: of at least ten shrinks that I have worked with, all of whom accepted ComPsych "insurance", I consider only two to be "normal", and only these two were of genuine help. Furthermore, when I asked family doctors to recommend psychiatrists whom they thought weren't crazy themselves, in each case, the ones recommended wouldn't accept ComPsych referrals, and their fees were extremely high, in the $400/hour range or more.

Side note: Do you know that guy who goes in with a screwdriver and needle-nose pliers to defuse a bomb? His work is worth $400/hour, and perhaps even more. Anybody else on the planet, no matter who, should not be paid more than half that. Period.

The last one I saw, I was pretty impressed with, at first. At our first visit he reviewed my case in detail, and we talked for a half hour. Then, thinking out loud, he ran through a differential diagnosis to reach the conclusion Dr. Valentine had reached several years earlier, of Bipolar II (the milder type, but still distressing enough). He suggested Abilify, an "atypical antipsychotic", which is also useful for reducing the distress of depression, but doesn't much affect mild mania. As he put it, "We'll let you have your fun," because hypomania is a happy state, while full-blown mania is torment (as I've been told by two friends so afflicted). The main side effects of Abilify for me were a little weight gain and the need for a daily nap. Otherwise, it was pretty good. However, after a year, going in for a third visit, I was planning to ask if there might be something better. He was gone. Vanished. No trace. No sign or note on the office door. Other doctors I've had who moved away or left the business at least had the grace to inform their patients. At that point, I decided I had learned enough about mood management to live without psychoactive medications, and I have done so ever since, for almost 15 years.

Reading Psychiatry and its Discontents, by Andrew Scull, I find that the differential diagnosis used by this doctor may have sounded good, but whether it was scientific or even medically accurate is not so certain. Based on my experiences over the years, for at least this condition (Bipolar II), I think the basic criteria the doctor (and Dr. Valentine) used are useful. In other cases, perhaps not so much.

Professor Scull's book mainly consists of prior articles and book reviews, edited for coherence, and it is a historical review of the various incarnations of psychiatry. Prior to the late 1800's those who worked with the insane were called Alienists, because the older meaning of "alien" was "insane". Once the word "alien" picked up the meaning "foreign", the ambiguity gradually led some to seek a new term. The Greek word "psyche" refers to the soul or mind, so that was a good prefix, and on it went.

Whatever one calls them, those who treat the insane (and the "sorta insane" like me), have always been sort of stepchildren of the medical profession. Apparently, after decades of working empirically (at best!), in the mid-1900's psychiatrists felt the need to establish their work on a more scientific basis. The process is dealt with, over the space of several chapters, and is a sad history at best. The result was a total of eight editions of a guidebook called the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The current edition is DSM-5, a thousand-page tome. In the view of our author, the first "official" version, DSM-III, released in 1980, was "an anti-intellectual collection of categories jammed between two covers". Later editions only compounded its errors, and much greater errors were gathered to comprise DSM-5.

It is a rather difficult for a layman to consult DSM-5 to see for themselves what is going on. Firstly, it is enormous, 947 pages, covering 297 named "disorders"; it is expensive at $199, or $149 for the paperback. There is a little bit of information available without cost. I took a look at some of the Fact Sheets found at this page. One of them is titled Personality Disorder, though the sheet itself is titled Personality Disorders, and lists ten items in the first paragraph. Look at this list, mentally appending the term "personality disorder" to each item:

• paranoid
• schizoid
• schizotypal
• antisocial
• borderline
• histrionic
• narcissistic
• avoidant
• dependent
• obsessive-compulsive

If you dig into the characteristics and criteria used to "diagnose" any of these, they are nearly all rather mild extensions of ordinary tendencies we all pick up over time. In the discussion on the Fact Sheet, four of these are somewhat deprecated—frankly, they are redundant, being covered by other items dealt with elsewhere—leaving the six I have highlighted to be dealt with in the body of DSM-5. Prof. Scull states several times that most of the 297 categories in DSM-5 are inventions of the drug companies that effectively "pathologize" common behaviors so drugs can be sold to the "anxious well", people who are quite sane, but easily convinced to worry about their mental health.

Why is DSM-5 important? The insurance companies have adopted it as the "standard" upon which they are willing to pay. Shrinks everywhere have to put a diagnostic number on a prescription or treatment schedule or they won't be paid by the insurance company, and in most cases, the patient can't afford to pay. Sadly, most of the categories are, in my view (developed years ago), bogus.

The Autism Spectrum was invented, practically out of whole cloth, during the production of DSM-5, which was released in 2013, but "the spectrum" was being bandied about earlier. Before the 1990's about one child in 500 was counted as autistic. A much smaller number, formerly called "high functioning autistic" were later said to have Asperger's Syndrome. "The spectrum" produced millions of new "victims", such that one person in 90 is now "on the spectrum". I have several friends or acquaintances who are considered "on the spectrum." Actually, with one exception, they are just shy and a little withdrawn. Big deal. So was I. I suppose I could, even now, go get diagnosed and get some kid of Federal "help". I'd be mortally ashamed to do so.

My grandmother, using an old term for "mildly crazy", would say, "Everybody's pixilated except you and me. Sometimes I wonder about you." Extend that to the psychiatric profession. Most (not all!) of the psychiatrists I've known are earnest and honest, but it is certain that a significant number are just cynical enough to be willing to profit if the entire population were to be brought under their "care."

I won't get into the horrors that "mental care" entailed in the past, nor many other aspects of the book. Psychiatry has the lowest rate of "true help" of all the medical and fringe-medical professions. It did help me, even though I eventually learned how to do better without any more "help".

I don't agree with some who say there are no mental illnesses (neither does the author). There can be organic problems with the brain, which is physical, after all. Some afflictions such as schizophrenia and bipolar and chronic depression may be organically-based. Also, there are stresses, particularly if they are severe enough or chronic, that require some people to develop defense mechanisms, and defensive habits are hard to break, even though their cause is no longer present. This is how most neuroses arise. We still don't know enough to go beyond that with any pretension of scientific credibility.

The book is, then, a history of a failed profession, and a polemic against its present incarnation as a practice enslaved to DSM-5, and a polemic against DSM-5 itself. I happen to agree. The two psychiatrists that I respect had a human dimension to their practice that went far beyond totting up a checklist of my symptoms to get me in the right pigeonhole. They did their best, with both hands tied, to treat the whole person that I am. The current state of psychiatry, as seen in this book and in the prior one, is well described as a tiny candle in a dark forest. Nobody yet knows how to bring any more light on the subject. Our brain and mind are still almost total mysteries.

Been Shrunk?

kw: book reviews, nonfiction, science, medicine, psychology, psychiatry, psychiatrists

I am pretty sure the number of psychiatrists I have engaged approaches ten. Only two were "normal", whatever that might mean. I have also had talk therapy with several other psychologists, and I remember only one who was someone I'd be willing to befriend.

Over the years I did, finally, come to understand that a psychologist or therapist is empowered only to offer talk therapy, while a psychiatrist, who may also conduct talk therapy, is an MD who can prescribe medication if needed, or prescribe visits to a therapist. I was rather slow on the uptake. I thought of them all under the derogatory heading "head shrinkers."

Up front disclaimer: I am considered "crazy" by many, and looked at askance by many more. The label I've earned is Bipolar 2: I am a middle-of-the-road mood cycler. Bipolar 1 is the more extreme version and shades into what I call Bipolar Zero: someone with maniacal energy for a few weeks at a time, followed by months of melancholy and reclusiveness, culminating in deep depression and perhaps a suicide attempt (or several); only to pop back into mania almost overnight. That is one pattern of the classic Manic-Depressive syndrome. My "mania" is called "hypomania", meaning sorta-kinda-manic, and my depressive periods are more a kind of introversion and withdrawal. I also cycle rapidly, with several cycles yearly rather than one or at most two, the more usual pattern. I suspected this about myself beginning about age 30, but it was more of an "I wonder" sort of idea for a long time.

At about age 55 I saw a psychiatrist and it was confirmed. This was the wise and lovely Dr. Valentine (I don't mind using her name; I'll defer for the others). She confirmed that I was Bipolar 2, and discussed several courses of action with me. I had gone to her when a short stint using Zoloft had the unexpected (to me) result of triggering full-blown mania. My GP, who had suggested trying Zoloft because I felt very depressed (more than my usual month-or-two-of moodiness), saw that I was manic when I saw him after taking Zoloft for two weeks. I was interrupting him—heck, I was interrupting myself!—and making all sorts of grandiose statements. At my most effusive, I had not been so grandiose before. Dr. Valentine prescribed a mild mood stabilizer. I don't remember which one (this was almost 20 years ago).

The drug eventually had side effects I didn't want to cope with, including the need for a daily nap. However, when I called for an appointment I found Dr. Valentine had moved her practice to another state. The mental health appointments were being paid for through a program at DuPont called Employee Assistance Program (EAP), which contracted work through ComPsych. I had to go through them to find an in-network doctor. No doctor I saw after this came even close to the combination of caring and expertise. Though they were competent, they were all rather off-center, and some were downright looney. I realized that ComPsych draws mostly from the bottom of the barrel: doctors who need the referrals because they couldn't stay in business otherwise. I could seldom stay with a doctor for more than a year or two, sometimes because I wanted someone less crazy than myself, and sometimes because they left the business or moved elsewhere. I live in an area that is poorly served because state laws are not very doctor-friendly. That means, whether a family doctor, a psychiatrist, or any specialist, about half the doctors around here are really altruists, serving where they know they are needed, and the rest are here because they couldn't make it in a more competitive environment. I have had some of both, in all areas (Luckily for me, when I needed cancer surgery, I got a true expert! But that's a story for another day).

I have to mention one example of "barrel bottom" psychiatry. I was sent to a psychiatrist because I had a suicidal episode. I was stopping a drug that made me gain weight and didn't help with depression all that much anyway. After a short, almost cursory interview, the doctor prescribed Depakote and gave me a bag with some samples. I was shocked. A friend of mine, who has more severe Bipolar than I, had been on Depakote and gained 90 pounds. I already weighed about 30 pounds more than I liked. I started to leave, and then I put the bag back on the desk and said, "You must be insane. This medication will make me even fatter than I am already. How will that improve my depression?" I walked out and I didn't pay the copay.

With many decades of experience with psychiatrists and psychologists under my belt (starting at age 12, but with significant gaps before middle age), I was quite interested to see Shrink Rap: Three Psychiatrists Explain Their Work, by Drs. Dinah Miller, Annette Hanson, and Steven Ray Daviss. The book is based upon the blog Shrink Wrap and the podcast My Three Shrinks, but it is much more than a simple compilation.

Each chapter uses one or two example "patients" to illustrate various facets of the work of the three doctors. Each "patient" is a composite, so as not to expose too much about any one person, who might be harmed by public exposure. Considering that some of the "cases" are mild, while others are quite severe, this is a valid concern. Consider "Josh", who is mostly pretty ordinary but has had some reverses. It is quite usual these days for an extended period of depression to prompt a doctor to prescribe Zoloft. "Josh" and his doctor found out what I and my doctor did: hidden Bipolar gets manifested by the general mood-lifting action of Zoloft. Josh's experience was more extreme than mine. And then, when he had a medical condition that was treated with steroids, he went full-blown manic, and needed to be hospitalized for a while. He missed a semester of college. The doctors who treated him had quite a job on their hands. It is kind of like accidentally starting a raging fire, and then trying to put it out without drowning everybody. And this was one of the milder cases.

I've had experience with clinical and therapeutic psychiatry. I was most interested in the discussions around forensic psychiatry. Previously I knew nothing about it. The word "forensic" conjures up doctors sifting for clues to a crime, or using DNA to confirm an identity, or not. "Forensic" is derived from an old word for "legal", so forensic psychiatry is its practice related to legal matters, such as determining the competence of a defendant whose lawyer is claiming an insanity defense, or judging the fitness of a parent in a divorce case who is accused of criminal abuse (if there is no criminal complaint, a different psychiatric specialist is consulted). A forensic psychiatrist will also interview a newly-arrested suspect who exhibits abnormal behavior.

There are a couple of chapters that weigh the relative merits of talk therapy versus medications. Both have their uses, but it is often quite a puzzle to determine which might be more effective. It has been said that the human brain is so complex that if there were only one human brain in the universe, it would contain within itself more than half the total complexity of the universe. Dealing with brain malfunction is thus the most difficult task of all. For many decades people have been studying human personality and its ills (actually, many millennia, though we usually set the starting point "only" two millennia ago with Aristotle). The study intensified in the past two centuries, beginning with Freud and Jung. Now in the early 21st Century, we are about an inch beyond the starting line in a "race" to figure out how to help people with emotional, personality, and brain malfunctions.

There is a lot more I could go into, and it is all very interesting, but I will bow out here. The book is like a textbook in some ways, though it is mercifully brief by comparison, and yet comprehensive. I came away with a better appreciation for the complex decisions that these doctors must make, and the great gulfs of unknown they must navigate. Heart surgery has been likened to doing an engine overhaul while the engine is running. Psychiatry is similar, except you can't even lift the hood to get at the engine. That limits things. I am glad that not every psychiatrist I dealt with was a bottom feeder; at least two or three were very helpful to me, in different ways and quite different times. The three authors of the book are based in the Baltimore area. If I need a shrink again (I hope I don't; I manage well without medication now), I might contact one of them!

Everyone is pixilated but me and thee, and I wonder about thee

kw: book reviews, nonfiction, psychology, psychiatry, standards, diagnostic procedures, polemics

The quaint country saying that titles this post may soon become reality, except that people in very official capacities will be enforcing it. Not a moment too soon, Allan Frances, M.D., who chaired the DSM-IV task force, has written Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.

DSM refers to Diagnostic and Statistical Manual of Mental Disorders. Editions I and II, released in 1952 and '68, were innocuous, and defined criteria for diagnosing a few dozen psychiatric syndromes. DSM-III (1980) and -IIIR (1987) greatly expanded the reach of psychiatry. Seeing how the diagnoses were being abused and expanded into "normal" territory, Dr. Frances tried very hard to establish standards for DSM-IV that would alleviate the problem. He didn't know the hydra-headed monster he was up against! The first direct-to-consumer drug advertisements aired in 1983, just over 30 years ago. By the time DSM-IV was released in 1994, drug companies had a 12-year head start inflating diagnoses, psychiatrists were also eagerly ramping up their business, and family physicians were beginning to get in on the largesse afforded by official recognition of a host of "afflictions" that were formerly considered within the spectrum of normal, or at least, ordinary, behavior and experience. Most of those diagnosed under the new guidelines will be, not the truly ill, but the "worried well."

My own experience with this has been rather peculiar. DSM-IV introduced Bipolar II (BP2), for persons with hypomanic (less manic than full-blown mania) episodes alternating with depression. In 2002, in the aftermath of a serious personal crisis and loss of a valued friendship, I could not shake off persistent depression after several months. My family doctor at first recommended an antidepressant. I tried several and the third try was Zoloft. When I saw him a few weeks after starting Zoloft I was bouncing off the walls. Now he said it might be BP or BP2, and sent me to a psychiatrist for a definitive diagnosis. BP2 it was, and after some counseling and trying a couple of anti-epileptic medications, I decided to learn to live with it. I could not find a doctor willing to prescribe Dilantin, which I had already learned is the most effective anti-epileptic to use for BP or BP2. It is old, off patent, and thus denigrated. Nobody seems to care that it works.

A few years later, after another depressive episode that included some suicidal ideation, yet another psychiatrist prescribed Abilify. It is very expensive, but it seemed effective. I noticed my weight gradually rising, so after a few years I stopped that, and I have determined that is that (I subsequently also lost 20 lbs; losing weight is a great antidepressant). I have cognitive methods to deal with my moods. Prior to 1995 I'd have received the "paid friendship" of a counselor as the only therapy, and it would have been sufficient. I'd have saved a few hundred dollars, and my insurance company would have saved 20+ thousand. By the way, my experience with psychiatrists who will accept an insurance plan such as Compsych is that they are really bottom of the barrel. I could never afford a "real" shrink, but brief contact with one or two made me realize how bad those I'd seen really were.

That thought brings me to a late section of the book, in which Dr. Frances recommends a few things. One is expanding the number of psychiatrists. Who recalls when the baseball leagues were expanded? What happened? The average level of play went down. Think about it. Major league baseball could only accommodate a few hundred of the very best players. The cutoff was arbitrary, limited by salary caps and other regulations. But there were, in minor league teams, players just a tiny bit less talented than the ones who'd barely made it into the majors. However, there were not several hundred at that level. Revising the leagues nearly doubled the number of players. Most of those added were well below star status. If we do encourage a great expansion of psychiatry in America, guess what the average newcomer will be like. Maybe a few will be really great, but not most. I must add that I do agree with many of the author's recommendations, just not this one!

Now with DSM-5 just released, which has much greater potential for diagnostic inflation and other abuses, it is squarely on our shoulders (we, the potential patients) to say "No!" to the attempts by drug companies and newly minted psychiatrists and newly empowered family doctors to redefine almost anything less than "I am perfect in every way every day" as abnormal and requiring treatment, the costlier the better. Here is my own short list:

• I decided long ago not to allow a doctor to prescribe any drug that I had seen advertised on TV. Make that your New Year's resolution, in place of the ones you've already broken.
• Make sure you have at least one or two good, good friends you can talk to when you are feeling bad.
• Don't allow the schools to medicate your kid. A normal grade schooler is inquisitive and active and has a short attention span. The current definition of ADHD covers more than 75% of children! But only if we allow it.
• If you do have a terrible affliction that time and talk ("watchful waiting") does not alleviate, then get help, but do not let your family doc prescribe Seroquel or something. Get referred to a psychiatrist and demand conservative treatment from the outset. The stronger drugs can have permanent debilitating effects, and if you use one that doesn't work anyway, you could find yourself in worse shape and with little effective help.

Well, this is a bit more scattered than usual. Read the book, it is an eye-opener.

I finished the book on the date of this post, but I am writing it 4 days later. I back date posts in such cases. I was out of state, and it always takes me a while to get over plane rides, but the trip was very good otherwise.

Normal is not a definition

kw: book reviews, nonfiction, psychology, psychiatry

What is normal? It depends. My Funk and Wagnalls dictionary has several definitions, and even the first, purportedly primary, definition is not definitive: "Conforming to or consisting of a pattern, process or standard regarded as usual or typical; natural." Do you see that last word there, "natural"? It conflicts with the rest of the statement. Properly speaking, the first 15 words define "normative". ("Normative" has its own definition a ways down the page, one which is identical in meaning to those 15 words) "Natural" is a good first definition, particularly when we realize that nature embodies a range of "natural variation".

For about 200 years, psychologists and statisticians have developed an understanding of the "normal distribution", also called the Gaussian distribution. It crops up everywhere because of the way variation is so often dependent on many factors.

For example, the height of uninjured, healthy, adult male Norwegians has a certain range and an average value (about 1.8 m or 71" or 5 ft 11). The height of a particular Norwegian man is derived from many factors. There are many genes that influence how large the body grows; and also the kinds of food he ate growing up, the amount he exercised, and perhaps his favorite sport all contributed to his eventual height. Now suppose an otherwise ordinary Norwegian has a height of 1.5 m (59" or 4 ft 11), and another is 2.1 m (83" or 6 ft 11)? Men with either height are rare. However, among male gymnasts 1.5 m is a bit short but not that unusual, and among basketball players 2.1 m is also not unusual. Are both these men normal? Actually, yes. That doesn't mean they are problem-free.

"Normal" among people who vary in all their characteristics is properly understood as a range of variation. A mathematical concept called the Central Limit Theory shows that the normal distribution has no clear limit in either direction. The formula for the probability distribution has a very small but positive value for a height of zero, and also for a height of 4 m. However, for a homogeneous population such as native Norwegians, the standard deviation is about 7 cm, and the probability for someone to be outside the range of ±3 standard deviations (called "±3 sigma") is about 1 in 750. That means 1 in 1,500 for men shorter than 1.62 m (64") and 1 in 1,500 for men taller than 1.98 m (78"). A man who is 1.5 m tall is at -5 sigma, and the one 2.1 m tall is at +5 sigma. The probability for each is about one in 3 million. There are about 5 million Norwegians, so we might expect to find, on average, one perfectly healthy man who is shorter than about 1.5 m, and one perfectly healthy man who is taller than about 2.1 m, in each generation.

At what point would most people look at a man walking down the street, who is either quite short or quite tall, and say, "That isn't normal"? Now we are talking about what is normative. The fact is, society tends to cater to people who are within ±2 sigma of average, in height, intelligence, and BMI, which are the main three things you can measure. That range, from -2 sigma to +2 sigma, takes in 95% of us. The other 5% are just expected to cope with a world that isn't really made for them; for example in the U.S. doorways are 2 m tall and countertops are about 0.75 m high. Those who have trouble coping often wind up being classified as "handicapped" in some way. They may be "normal", but they are not usual, and that causes problems.

There are other characteristics that are harder to measure: a tendency be trusting or suspicious, one's ease or difficulty of forming loving attachments, the quickness or slowness of "temper", or the tendency to be altruistic or selfish. With several dozen psychological dimensions available, it is distressingly common to fall outside the ±2 sigma range on at least one of them. Some psychologists estimate that about half of us, at some time in our lives, will have a "condition" that can be diagnosed as "abnormal", or at least, treatable. I find that a bit disturbing, and I am not alone.

Professor of Psychiatry Jordan Smoller has written the first book (that I have seen) advocating the study of normal psychology: The Other Side of Normal: How Biology is Providing the Clues to Unlock the Secrets of Normal and Abnormal Behavior. I just checked Amazon.com; there are more than 4,000 books with "Abnormal Psychology" in the title, and 47 published in the past 90 days. There are only 35 titles containing "Normal Psychology", but most of these are editions of Mental Pathology in its Relation to Normal Psychology by Störring and Loveday. It is pretty safe to say that Dr. Smoller currently has the field of normal psychology to himself.

The thesis of his book is quite simple. William James a century ago wrote that "the best way to understand the normal is to study the abnormal." The result has been a steady process of studying various pathological conditions and staking out a supposed range of behavior (a syndrome) to define it. There is no doubt that the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in version IV, has helped standardize communication among mental health professionals. However, the "edges" of the diagnoses are necessarily hard to specify, leading to continuing encroachment on "normal" territory. Only about half the people are still "normal", and that doesn't include me, because of my diagnosis as Bipolar II.

Is someone with a diagnosable condition, who can cope well with it, sick? Like many writers who are bipolar, I've learned the rubric, "When you are up, write, and when you are down, edit." For people in creative professions, a certain level of bipolarity is a benefit. It opens up a wider range of creativity, and also allows one those periods of narrowed focus necessary to prune the extra wildness off and complete work that might otherwise need the services of an expensive editor (painters and sculptors can't use editors, but writers and composers and lyricists can; and dancers' and actors' "editors" are called choreographers and directors).

I have two friends who are schizophrenic. One knows it and the other doesn't. The one who knows it used Thorazine for a time, but learned to cope with his inner demons so he could get off Thorazine, which has devastating side effects. He makes his living by tutoring in electronics and computer programming. The other fellow is institutionalized because it would take extreme force to put a pill down his throat. If left to his own devices, he hitchhikes around the country, which isn't bad in itself, but he can't earn money so he becomes a danger to himself. I guess I can't really call him a "friend" any more, since he can't reciprocate my friendly feelings. He is a likeable guy most of the time. I guess these men represent two ends (or near-endpoints) of a schizophrenia spectrum.

In seven chapters of the book, the author considers the intricate dance of genetics and environment (including family upbringing, if there was one) that influence a person's mental makeup—the genetics of behavior may take up 10% or more of our genome, so no one gene is the "gene for" any characteristic—; various ways researchers have used to tease out environmental influences; the surprising role of epigenetics, which is actually a non-Mendelian means of heritability; and the ways we can choose to change our behaviors (it ain't easy but it is possible!). He ends with a plea in favor of studying the normal ranges of behaviors, intending to turn William James's dictum on its head. It now seems better to study the normal so as to better understand abnormality.

In height, being tall is an advantage for getting a job and a mate, but being super-tall is not super-good. Men taller than about 2 m have paradoxically few jobs open to them. They duck through doorways; people stare at them (or try very hard not to stare). If they have exceptional athletic coordination, they might become professional basketball players, but for the rest, being unusually tall brings with it trust issues. It is also paradoxically difficult for those with extreme IQ's to get work. There are two issues here. Firstly, someone with an IQ greater than 160 probably grew up lonely. At +4 sigma, he or she was one in 32,000 and probably had no acquaintances of similar brilliance. This leads to significant social ineptness. Secondly, people with extreme IQ's have different interests, or you could say, they are seldom interested in things that interest those in the ±2 sigma range. This makes it harder to communicate with a boss or a customer. That is why Mensa was started.

In other areas, being "super" may not be possible. In the chapter on "Baby Einsteins", Dr. Smoller points out that an overloaded "learning" environment is probably akin to a hyper-oxygenated atmosphere. The body can only use so much oxygen. When we need extra, we breathe deeper, but going to the "oxygen bars" that cropped up some years ago didn't do the patrons any good, though it fattened the wallets of the proprietors. Alert: SCUBA divers know that pure oxygen at twice atmospheric pressure is toxic. If you fill your tanks with pure oxygen and dive deeper than 30-35 feet, you'll die; if you use regular air, you can dive to 150-170 feet, and then you'll die of oxygen poisoning. To go deeper you need special oxygen-poor gas mixtures. Fortunately, making your baby listen to Mozart music won't poison the little tyke, but it will not raise IQ.

So why is the "Mozart effect" popular? The studies upon which the craze is based are flawed. They didn't take into account the fact that parents who might play Mozart for their infants are also more likely to read to them, play with them, and take them places. That is what helps the kids' minds develop. Parents who plop a a little one in front of an "educational video" for a few hours a day will probably find the child is more passive in school and could have trouble learning.

So far, I have neglected the "biology" portion of the thesis. Our brain is biological. Most of modern pharmacology of behavior is based on a number of accidental discoveries that are some forty years old. Much more recent work with chemicals such as oxytocin is just beginning to hint that better chemical interventions are possible. Here is where Dr. Smoller's caution is advisable: we really, really need to know what is normal before we do any more manipulation of people's minds. Otherwise, how do you know when they are "better"?

How do you define success? This lack of a defined target leads to people who spend years and years in psychoanalysis, with little change. Aimless maundering to a clueless therapist is like circling under a lamppost, just because that is where the light is. A proper study of normality, and of the amazing adaptability of all of us, can shine more lights where today most are groping in darkness.