Is Walter White a Psychopath?

 Walt’s pathological and Machiavellian level of manipulation of others, even those who might describe him as a friend, makes us question who the real Walter White is. Is he a psychopath? Is he a guy who suppressed his basic needs so much during his life that that now he’s just having a narcissistic tirade to prove he’s all-powerful as he approaches death? As a psychiatrist, I view the evidence that points in one direction vs. another. As a writer, I see the brilliance in how we’re led into watching his dark side unfold, while still empathizing with him.

Modern psychiatry can’t give definitive answers about a diagnosis for Walt, because the field itself still has debate on even where to draw the line on what makes up a psychopath. Plus he’s fiction.  It does give us some good bearings, though.  There’s the DSM definition (antisocial personality disorder), there’s research models used in forensic evaluations like the psychopathy checklist revised (PCL-R), or the Psychopathy Personality Inventory. There’s Cleckley’s work, and the Macdonald triad (bedwetting, firesetting, cruelty to animals). There’s even ideas floating around of a “multi-hit” hypothesis, with genetics, child abuse sometimes, head trauma all playing a role.  Each of these have some level of support, and all have significant amounts of criticism.

Walt began as an inhibited chemistry teacher, presumably for over 16 years. He obeyed the rules. He paid his taxes. He followed the rules, but he was miserable. Then he passes a turning point. His cancer diagnosis means he has nothing to lose. In a way, his reasons for restraining himself and obeying the rules are removed (or lessened), since living a long life out of jail has less meaning. At the same time the incentive to break the law rises in his mind, which was to help others. In that way his breaking the law seemed justifiable, which makes it easier to follow him as viewers and keep him sympathetic. At least at first. As he descends into the world of methamphetamine production, we see him unleash a very different side of himself. This raises the question for viewers: what kind of a man could do such horrible things and not seem bothered by it?

Now I’m not a forensic psychiatrist, I’m a psychiatrist and writer who tries to follow the research as best I can. So let me do my best to boil down some concepts.

There is not one definition for being a psychopath. Or  a sociopath (interchangeable term for many experts). The wiki page isn’t bad at summarizing some of the different takes on the definition.  There’s specific common criteria, which can include a lack of empathy, lack of conscience, violence or cruel behavior (sometimes impulsively), manipulation, superficial charm, lack of remorse.  As you can imagine, many of these overlap, and someone can have some of these traits without having them all.

“God, I’m so antisocial.” I hear this thrown around a lot by people who don’t want to be around other people. They actually mean asocial, rather than antisocial. Antisocial can be conceptualized as going against social rules, particularly in a criminal form.

The DSM, starting with DSM-III, began listing a type of personality disorder called Antisocial Personality Disorder (ASPD). ASPD was intended to list what Cleckley (a grandfather in the field) was finding in those who went on to have dangerous and violent personalities. Unfortunately, like much of medicine by committee, the results didn’t quite map out to be valid in all real world situations. But the forensic psychiatry and psychology fields continued to do research. They developed the idea of psychopathy as possibly more of a trait, supported by the PCL-R.

When we hear the word psychopath, we think of serial killer. Psychopaths would usually meet criteria for ASPD, but not all those with ASPD are psychopaths. I lump ASPD into two categories to simplify an explanation – con men and serial killers. Con men lack a conscience, and generally don’t see external rules as valid. They have a level of narcissism, viewing themselves as superior, and acting in whatever way ultimately serves them. They can be very superficially charming to get what they want.

Serial killers, though, might be a different breed. They have a higher level of the psychopathy trait (think of it like a spectrum from none to a lot). With that comes a lack of fear in circumstances that would arouse fear, possibly explaining the need to be violent to feel physiologically elevated. J. Reid Meloy, a forensic psychologist, likes to talk about psychopaths as “intra-species predators.” Think of a wolf hunting its prey. Normal people if they had to follow or hunt someone would get nervous during the chase. Their heart rate goes up. They might be sweating more or deal with conflicted emotions in the process. A psychopath has the opposite physiological response when hunting. They get calmer. Their heart rate goes down. It’s possible that they’re an evolutionary development, which may have been advantageous in tribal times when killing was necessary for the group survival.

Property of AMC TV

Property of AMC TV

Both the con man and the serial killer lack a conscience. They both do what society deems as terrible acts or unacceptable acts for their own benefit. The difference is that the con man does it moreso for his own selfish gain, or to get away with something. The serial killer more likely does terrible acts because he enjoys it, because nothing else gets him excited. Even more importantly, the serial killer more gets excited from physically hurting others, from causing others to suffer. This starts in childhood with hurting animals, which in the DSM is one of many criteria for conduct disorder (considered the precursor to ASPD).

So we come back to Walt. We as viewers are a little shocked because he has gone from a schoolteacher to the most deceptive man in New Mexico. He has lied to his family, co-workers, and many others, all for his own gain. It seemingly all started as a selfless act, that of supporting a family. It eventually grew into the “Empire business,” serving his own ego. Every morally questionable acts that he does, though, is for a particular aim. He’s able to justify it in a twisted logic based on his business. He doesn’t seem to have any of the childhood precursors of conduct disorder (that we know of) such as fire setting, animal cruelty, truancy. He doesn’t seem to necessarily enjoy killing people, but will do it when he deems it “necessary.” So he’s closer to the con man than the serial killer spectrum of psychopathy.

Jesse is even lower on the spectrum.  He probably met criteria for conduct disorder as a kid.  He broke the rules and made meth because it seemed advantageous to him.  He is Walt’s counterpoint.  He seemed like a bad kid who had lost his way.  He was the criminal, and based on the superficial way we think about criminals we’d think he’d be the bad one.  He was a wanna-be criminal, wearing the guise without the internal lack of morals.  He crossed the line with murder.  This triggers his conscience, which makes him question all of his life.  He is less than a con man.  He can barely lie.  He doesn’t fool anyone.  He has remorse.  Interestingly, only by Breaking Bad was he able to find his way back onto a path.


A deeper curiosity arises from this discussion, portrayed periodically in the media: are there psychopaths among us, who are not criminals? Some theorize that psychopaths with certain environmental circumstances may have social opportunities to channel their predatory instincts. I’m not talking about Hannibal, necessarily. If someone thrives on hurting or taking advantage of others, what job opportunities might fit them? Perhaps those with competition or built in deception? Business, sales, some sports, even some fields in medicine that thrive on competition (I’ve heard ideas about some of my surgical colleagues), all could be possible. Snakes in Suits covers this topic in more depth, where psychopaths can thrive in certain work environments.

Walt clearly has psychopathic traits, but we’re led into liking him in the beginning because he seemed to break the rules for good cause. We follow him, hoping for his redemption. Our curiosity though might reflect our own hidden impulses, played out in a safer way onscreen than in our real lives. It’s not that we are evil, but that with every attempt to force ourselves to be one way, an opposite side can develop to a degree. Thankfully for society, most of us don’t unleash it the way Walt does.

If you’re a Breaking Bad fan, I’ve contributed to a number of articles on Vulture.com about the show.  Find the links on my media page.


Why I hate Xanax

A lot of people like Xanax. It’s given out like candy. People get it from their friends, from their primary care doctors, even from their psychiatrist. I hate it. I might go so far as to say it’s evil, though really it’s just bringing out the worst aspects of our nature. In my professional opinion, it’s bad for you.

But no one wants to hear that.

Yes, it feels good when you take it. People take it for anxiety. They feel less anxious (usually) after taking it. Must be working, logic would dictate. Unfortunately this is short-sighted, in the same way that we as a collective society (and medical establishment) view pain as something to annihilate.

Xanax makes you feel good. It brings on euphoria. Heroin feels pretty good too. Feeling good from it doesn’t mean it’s good for you. In fact it is this hedonistic approach of minimizing anything uncomfortable [painful] and maximizing pleasure that leads to more problems with both pain and anxiety. I’ll discuss pain in another post, particularly the overtreatment of pain as a phenomenon which is leading to a significant number of deaths from prescription pain pill abuse and misuse. Here Xanax needs to be addressed.

“My doctor prescribed it for me, so it must be safe.”

“The FDA approved it, so it must be safe.”

In truth nothing is absolutely safe. Water will kill you if you drink enough of it. Seriously. Every medication has its potential benefits and potential drawbacks. You are not guaranteed to get either the benefits or the drawbacks. It’s really a numbers game. Do the benefits outweigh the risks? In Xanax we both overestimate the benefits and underestimate the risks. And those that prescribe it like candy have a fundamental misunderstanding of how anxiety works, in my opinion.

Over and over again I hear –
“But you have to give me Xanax. It’s the only thing that works for my Anxiety.”

Really it doesn’t. It’s giving you the illusion that it’s helping, because it seems to give temporary relief. And it does. It works really fast. It gets into your system quickly, and feels really good really fast.

And then it’s gone.

The anxiety returns. Even worse, there may be withdrawal anxiety as the medication comes out of your system, bringing up all the feelings that your body and mind are out of control. So you turn to the same thing that seemed to help, even if temporarily: more Xanax. As you take it on a regular basis, possibly with increasing amounts, your body becomes tolerant to it. Tolerant means the same amount doesn’t have the effect it used to have. So again you need more of it. If you start to worry about the possibility of anxiety (anticipatory anxiety), you can then make yourself more anxious. Then you’d need a Xanax just to prevent the possibility of something bad happening.

I wish this was a fanciful diatribe with no grounding in reality. I’ve seen hundreds of these patients in my relatively brief career, caught in exactly this cycle.

The basics
Xanax is a benzodiazepine (aka benzo). It’s a tranquilizer. The same drug “family” includes clonazepam (klonopin), diazepam (valium), lorazepam (ativan), chlordiazepoxide (librium), and others. Xanax is notorious because it has such a short half-life, meaning it lasts in your system a brief amount of time. Surely the longer acting tranquilizers must be the better approach? Perhaps. Some people do function on benzo’s. That isn’t really in debate. The question is whether they function better with them than without them, in the long-term, and if there isn’t a safer alternative. In my opinion, they’re a third or fourth line approach, at best.

Anxiety is uncomfortable, and people in our culture don’t want to be uncomfortable. At all. Ever. So logic would dictate we should try to annihilate it. If something helps a little, use it a lot.

This is the rationale that actually leads to anxiety becoming an unremitting problem. Trying to keep it in check, to hide from it, or to hold it at bay, all feeds the problem. Fear is the problem. Psychotherapy figured out the truth: the way to lessen anxiety is to face it, not avoid it.

I had a patient once who had panic attacks. I think of panic attacks as the worst kind of anxiety, so severe it can feel like a heart attack or like you’re dying. He grew up on the streets (homeless for much of his life), coming from a tough childhood. He never had anyone he could trust. He got over his panic attacks without medication, and even without therapy. He had tried Xanax and other meds, and was on the slippery slope of trying to manage the anticipation of anxiety by using more and more benzo’s.  He would think about how bad anxiety could get, and would get anxious about that, and so would end up taking benzo’s just to prevent possible anxiety.  He was getting more and more addicted.

Then one day he got fed up. He was having a panic attack, and felt the fear of dying.

He shouted at himself, while beating his chest, “just fucking do it! Just fucking die already.”

He welcomed the worst possible consequence. And immediately the panic attack went away. The fear fed the panic. When he stopped fearing it, it deflated. It was still uncomfortable, but it didn’t build up the same way. He cured himself.  He doesn’t have panic attacks anymore.

If you want a medication for anxiety, look at the whole picture.

“I only want to take something as needed.” Your anxiety is all day, though. You have brief periods of it getting worse, but the rest of the time there’s some anxiety. So really you need something that works all day. You’re falling into the fear of chemicals while still wanting some chemicals. The issue is that the ones you’re asking for perpetuate or worsen the problem, rather than improve it. It’s a lot harder to treat anxiety in someone already addicted to benzodiazepines than someone not. Thus the slippery slope of good intentions and short-term outcomes.  And I believe medical providers with our good intentions cause more iatrogenic problems with this than we do help people.

The other risks
Unlike other medications for anxiety, the risks with benzodiazepines are much higher. Primarily the risks are seizures and death. If you take too much, you could get oversedated and die. If you mix it with anything that makes you sleepy (or pain medications), you could get oversedated and die. Withdrawing off of benzodiazepines can bring about increased anxiety, but more importantly the risk of seizures. Alternative medications like SSRI’s while not perfect, have far fewer risks to them, and are thus a much safer choice.


–postscript.  Yes, I float between the 1st/2nd/3rd person.


Anti-Heroes Embodied: The Act of Killing

We love the bad guys. Scarface. Tony Soprano. Vic Mackey. Walter White. The Anti-hero is king in the world of TV and Film, especially of late. It’s probably a fantasy fulfillment, at least to some extent. We love to watch that unacceptable part of us get unleashed, just temporarily. We can barely imagine what would happen if the bad guy was unleashed permanently. What if his killing was legalized, even state-sponsored?

Without stating it, that is the subject of the documentary The Act of Killing by filmmaker Joshua Oppenheimer, produced by Werner Herzog and Errol Morris. A long time ago in a land far away from our Western “sensibility,” in the country of Indonesia, there were death squads. In the 1960’s, they killed Communists. They killed those accused of being Communists. They did it mercilessly. They did it with the backing of many groups including the US. Imagine if Joe McCarthy in the 1950’s started squads to exterminate everyone accused, rather than have the House Un-American Activities Committee to try them?

In Indonesia in the 1960’s there were no trials, and over a million people were murdered. The perpetrators were never tried. They now run the government. They’re proud of what they did. And they proudly call themselves “gangsters.”

Oppenheimer approached the heads of the former death squads, many of whom are now political leaders in the country, with the offer to have them re-enact the death squads in any way they choose. We follow them, as viewers, as if they’re the protagonists.  Now I have hypothesized about fictional anti-heroes and how we can empathize with them.  The Act of Killing layers a fascinating portrayal of a group of gangsters re-enacting their horrific acts proudly, with little sense of the basic moral code of the rest of the world. In their minds they are the heroes. What unfolds is a revealing portrait of mass murderers, and the rationale that goes into their creation and maintenance.

Now in their 60’s and 70’s, these men show no remorse for their acts.  The exception is the focus of the documentary: Anwar Congo.  He is celebrated by his cohort of gangsters, but hints at regret.  He has nightmares of those he killed, but he doesn’t understand why.  Nor do his colleagues.  We watch Mr. Congo with the vague inkling that he might be more moral than the rest.  He teaches his grandchildren to be nice to a duck, and apologize to it after they’ve hurt it.  For almost 50 years he has held the title of hero in this world, and never allowed regret to fully rise up.  In a world celebrating gangsters, regret might be viewed as weakness.

These leaders have shaped a narrative where they equate “gangster” with “free man,” (they state this definition publicly), and have sold the public in Indonesia on this twisted definition. As if being free means being able to kill without consequence. We (Americans) helped to form this narrative.  In this part of the world they still believe themselves as heroes, the champions of their land, free to take and do what they want.  Even their portrayal of the afterlife for their victims is glorified, as if the killing is justified.


When they retold the history leading up to the murders, Anwar Congo  describes how he watched American movies of the 50’s and 60’s, including the celebration of gangsters. This doesn’t serve our usual rationalization in the US that TV violence doesn’t cause real violence. In this case, it at least inspired it, though may not have caused it.

There is a discussion between the main focus of the doc (Anwar Congo) and his friend/associate. They are both former heads of the death squads. In many respects they both appear without remorse, without perspective on the atrocities they’ve committed. Anwar Congo, while holding the party line that this is an act of pride, confides in his friend that he continues to have nightmares to this day. His friend recommends he go see a psychiatrist. But that would mean he’s crazy. So of course he wouldn’t go to see a psychiatrist.

In a world without the presence of morality, the one individual who has regret leaking through in his dreams must be crazy. It would be useful for him to see someone to talk about it, particularly someone who might recognize the cultural insanity that allows a group to murder their own people and justify it based on politics. History has never validated such acts, despite what the perpetrators rationalize for themselves in the moment that they’re doing good.

And yet in this society of Indonesia, few have awoken from the delusion. They keep their conscience in check by fear alone. Perpetuating a message of “freedom” through violence, as if being free means being able to act with impunity, these war mongerers have created an environment that reinforces this false belief system.

Sitting in the theater, the silence among the audience is astounding. The villains got away with it. There’s little karma apparent in a world where millions can be murdered and governments do nothing. So we all watch with an impotent sorrow. Horrible acts with no resolution. The dead stay dead. The criminals stay free.

Eventually we see a small change in Mr. Congo.  After decades of holding back the reality of his actions, he finally experiences it when he chooses to portray a victim in the re-enactment.  He can’t stand it, from the choking to the threatening.  The final transformation occurs when he watches the film of himself as the victim, and a transformation seems to take place.  For the first time in his life he considers the possibility that he really made people suffer.  Somehow he kept that locked away.

Following his realization, we watch an extended scene of him retching, dry heaving. He has swallowed propaganda his whole life, and only now, in his 70’s, is he able to try to vomit it out.  But nothing comes. Our Anti-hero cannot get it out him.

As a doctor and psychiatrist, the film reveals the humans behind the terrible acts.  They are people that did terrible acts.  Many just seem unfortunate, misguided by the false idealization of violence and power as empowering.  We could construct a context to their origins and explain these horrible acts, perhaps informed by the work of Philip Zimbardo, where we understand that these men were young at the time, in a period of social upheaval.  They came from poverty, and saw a chance to seize power.  Their society may have stripped away the identity of the victims as people.  That may lessen the reality of the individual though.

As a storyteller this reveals to me that the Anti-hero needs some bit of grounding to be sympathetic. Some lines can’t be crossed, some acts aren’t forgivable.  His colleagues seem unforgivable, as they have no regret.  Even Mr. Congo strains a connection to the audience.

In the end the  film holds a mirror up to the celebration of violence, reminding us of the division of fiction and reality, and challenging our usual internal emotional disconnect when we watch violence.  It’s a haunting view of our shadow selves.

See more of this film at: http://theactofkilling.com


Chemicals, Depression, and the Mythos of Natural

Usually by the time a depressed person comes in to see me, it’s because what they’re doing hasn’t been working.  Therapy hasn’t been helping, or they don’t have the time or finances to do therapy.  So as a psychiatrist, I offer an antidepressant.  And almost every day, people hesitate.  They don’t hesitate because they doubt whether the medications work (a separate debate).  They hesitate because they want to follow a “natural” lifestyle or philosophy.

Now I follow a principle of using as little medication as needed, recognizing a propensity in many colleagues to use more and chase every symptom with another medication.  But I disagree that “natural” means better in healthcare, as the foundation of a lifestyle of “natural” and “organic” is at its core shaky, particularly when it comes to depression.

Behind this lifestyle lies a bias against “chemicals,” as if all “chemicals” = “poison.”  As if there exists a homeostatic mechanism in humans that will protect them from disease if they remain “pure” enough.  This demonizes medicine and perpetuates a false model that the human system (body/mind) is inherently self-healing and self-correcting (a philosophy perpetuated in many alternative health models).  Disease occurs because the system isn’t working anymore, often despite a “natural” lifestyle.  And yet like anyone entrenched in a belief system, when something isn’t working anymore, rather than doing something else people just do more of the same.  More extreme of the same.

The “natural” lifestyle could be partially a backlash against the overmedicalization and overmedication of every condition.  I understand that.  I can only blame my own field, where the trend of using medications exclusively causes a distorted view of chemistry as a solution for everything.  This comes at the expense of what many seek in therapy, which is someone to listen.

The backlash against overuse is underuse.  Antidepressants are all too often given out for mild complaints, or temporary depression and anxiety.  This leads to the myth that antidepressants are useless, and even that “depression is natural.”  People get concerned about getting treatment for their catastrophic depression because “it’s natural to feel this bad in these bad circumstances.”  They hesitate because maybe depression is adaptive.  And it is, to a point.

There may be an evolutionary basis to depression (see research by Keller and Nesse).  Crying may have been selected for as a mechanism to help a person get social support.  The low energy and interest of depression may have been selected for as mechanisms to conserve energy in the face of an impossible goal that can’t be relinquished.  In the way having sickle cell trait (a single copy of the gene) appears to protect against malaria, some genetic developments help support life in a milder form.  But when the development is in a more extreme, it isn’t adaptive.  Sickle cell disease (a more severe type with two copies of the gene) isn’t more helpful than sickle trait against malaria.  A sickle cell crisis can even kill a person.   Similarly severe depression may be an out-of-control version of something originally adaptive or beneficial.  To follow a model of statistical normal distribution (the bell shaped curve), it’s an outlier, where the mechanism is causing harm rather than helping.

Of course there may be conditions that are environmentally caused.  That is not in debate.  Some cancers are definitively caused by chemical exposure.  What is less clear is if “purification” leads to remission from environmentally caused problems.  If it’s “stress,” can we realistically avoid all stress?  Probably not.  Avoidance with stress is almost never helpful.  Just as “bed rest” for back pain is in fact harmful, not helpful.  An alternative to avoidance should be to utilize alternative ways to handle the environmental problems.

Physicians, as a profession, are inherently anti-evolution, in its traditional sense.  Evolution occurs through natural selection, where environmental stressors kill off the “unfit” or weak.  Our job is to help those that might not function as well without help.  We’re a modern social invention to assist more of humanity to survive.  In the first world of plenty, there’s fewer selective pressures.  So apparently people are constructing their own, letting their ideals get in the way of their lives.

Everything is chemical.  The state of being depressed is chemical, in that there’s a chemical process going on in the brain.  Medications change those chemicals.  Therapy changes those chemicals.  Food has chemicals.  Herbs, often touted as “natural,” are just weak medications that are less regulated (so you don’t know how much you’re getting), and less studied (so we know even less if they help or hurt).  The idea of ingesting “foreign” or unnatural chemicals ignores the reason medication exists.  Medication does something for your body that it can’t do on its own.  An antibiotic, which is a foreign, unnatural chemical, that gets through your entire body often into your brain as well (thus its utility), is necessary when your own body can’t fight off an infection on its own.  Few people think twice about that.  It’s acceptable, most likely because it’s temporary.

I hear all the time in passing people present the rationale “well if cave men didn’t do it, it must not be healthy.”  Paleo diets, organic air fresheners.  The evidence actually isn’t that good as to the life expectancy of ancient man, but we can be sure of one thing now:  we’re living longer.  So we’re doing something right.  Modern medicine helps people live longer.

In primary care, usually people are unable or unwilling to make the necessary lifestyle changes to keep themselves healthy.  They won’t exercise or quit smoking.  In psychiatry it can be about the same issue, that of getting someone to admit that what they’re doing isn’t working, and that doing more of the same isn’t really a solution.  This is an issue throughout all of life, not just medicine.  If telling a patient to exercise more isn’t getting them to exercise at all, telling them more often isn’t going to make them do it.

If it can be done “naturally,” terrific.  Therapy is great.  I treat with psychotherapy as much as I do with medications.  But if you’re waiting to see if being natural will help with depression or any other medical problem, determine where the “point of no return” is, where it’ll be too late to take advantage of the treatments right in front of you.  Is it when death is near?  Is it when you’re hurting those around you?  Consider the point when following a lifestyle comes at the cost of your life.


Is it Bipolar, or not?

Jesse, a 27-year old guy comes into my office because he had a “rage” attack at his boss. He might lose his job. He’s overweight, not particularly self-conscious with a receding hairline and dressed like he’s still in college. He got upset when his boss criticized his work, so of course he lunged at him and punched.

“But that was just my Bipolar.”

No, it wasn’t. Because you don’t have Bipolar.

Of course I don’t say that.  Directly challenging doesn’t often serve the situation or help them to understand what’s happening with them.  It would only put them on the defensive.

The term Bipolar, like so much terminology, floats in the zeitgeist right now, and is all too often misunderstood and misused. And that’s partly because the field of psychiatry itself is conflicted about it, for a variety of reasons including conflicting and controversial research published, changing the shape of clinical practice, and frankly misinformation disseminated in the training process.

On the theme of questions I hear regularly (in this case, daily), people wonder if they have Bipolar disorder. Which raises the real issue as to what is bipolar, and what isn’t it? And the overdiagnosis of it. And the gray areas. It’s not so easy as we might think. I’ll refer readers back to my post about understanding the mind/brain being comparable to physics, because that’s particularly applicable here.

Let me take just a moment to explain the development of psychiatric diagnoses. We began as lumpers, and now we’re splitters. We’re moving from categorical diagnoses (either you have it or you don’t) to dimensional (everything on a spectrum). The more we learn, the more we appreciate the diversity of people. But we still have to come up with strategies to approach them.

So I’ll begin by mentioning how often I’m un-diagnosing bipolar in my practice. I see patients almost daily that tell me some doctor somewhere diagnosed them with bipolar. And a high percentage of the time it isn’t true. It’s based on a host of soft rationale, that ultimately don’t hold up. It’s useful to know how we got here.


Black and White

Technically psychiatrists and other mental health professionals try to follow specific manuals to help guide diagnosis. In the U.S. We have the DSM-IV (now transitioning into DSM-5), and in much of the rest of the world there’s the ICD Blue Book. We’re not required to follow them. They’re guides. Both of these define Bipolar as presence of severe depression and manic episodes.

Now to be specific, a manic episode involves feeling “elevated” (excessively happy or energetic), and having so much energy you might appear irritable or too happy. In particular a person having a manic episode will not feel like they need much sleep (a couple hours a night), because they have so much energy. And they’re staying up at night doing activities, starting projects, oftentimes which don’t make any sense later. Kay Redfield Jamison, a psychologist who writes about her own experience with bipolar disorder, describes spending $10,000 on snakebite kits while manic, because she thought it’s what the world needed. This is the real deal. Once you’ve seen someone fully manic, for days or weeks (NOT hours), there’s no mistaking it.

I made a little picture to illustrate Bipolar I. The elevation is a manic episode, the dip is a major depressive episode. This graph is characteristic to classic Bipolar.

Bipolar I

Now individual symptoms of a manic episode can be non-specific, which is why it’s important to really get a thorough history with someone who knows what to ask. When asked about going periods without sleep, many people will endorse periods of insomnia. They’re spending their nights tossing and turning. They might even go on to report racing thoughts. This combination is all too often misdiagnosed as mania, when really it could just be anxiety. The difference comes across in the reason for not sleeping, being too much energy vs. too much anxiety, and in the quality/type of activities done when not sleeping. Many people think periods of anxiety, or feeling upset is mania. Much of the time it isn’t.

Jesse tells me how he must be manic because when he gets “set off and manic,” he’ll stay angry for “hours.” It’s hard to calm him down. People tell him his anger is out of control. And yet it isn’t Bipolar.

A manic episode should last for about a week based on the current guidelines, with the elevated mood (or anger/irritability), not needing sleep for the whole time, spending excessive amounts of money, disinhibited behavior, grandiosity. But it’s episodic. It’s not something that goes on for years. And it’s longer than hours. It comes for a period and then is gone. Typically a person gets into some type of problems during this period. They get arrested or hospitalized, because their energy is so high they can’t control it. Maybe they even think they have special powers (grandiosity).

The other side of having bipolar disorder is having depression. Now that’s not an hour here and there. Most people have that, of maybe feeling a little sad or down. “Major” Depression has to be most of the day (more than 12 hours) for two weeks.

So Jesse doesn’t fit the picture of Bipolar. That isn’t to say he isn’t having problems. He’s still struggling. It’s just that Bipolar is the wrong term for it.

Now of course there are people who are just really poor historians. They may have manic episodes and not even remember it. There’s a phenomenon called State Dependent Memory, where we remember based on our internal state. It’s easier to remember something when feeling similar. Therefore it’s harder to remember a depressed period of time when not depressed (I actually theorize that this may be partly responsible for memory loss in ECT). Therefore, ideally, it’s a good idea to have collateral information, which is sources other than the patient. This might involve hospital records, or reports from friends, that might give more specific criteria as to how symptomatic someone has been in the past, and fill in the gaps of their memory. Occasionally I’ve been shocked by information I get, where someone who really didn’t seem bipolar had a manic episode somewhere in the past. Usually not, though.

People get very attached to their diagnosis. Maybe it gives them other resources in life, be that money, attention, or otherwise. Maybe it helps them to explain something about themselves, to find meaning in a world that often feels like it doesn’t have meaning. And in others it’s a way to excuse behavior that they feel they can’t control, or that they later regret.

“Oh, that was my bipolar.”

“I get totally manic every time that person says something to me.”

Probably not.

Now all of that is really just the first layer. It’s what the textbooks define as bipolar. It’s a categorical diagnosis. In particular the description above is for what’s called “Bipolar I.” When we start moving into a dimensional understanding, we get into the gray area. There’s Bipolar II, which is the same kind of depression, but only having to have a hypomanic episode (less severe of an elevated mood, doesn’t have to last quite as long). Then there’s other types of bipolar listed in the DSM and ICD Blue Book, like cyclothymia (mild depression and elation, not related to life events).

And still this is really just the textbook. And the textbook is always incomplete, even with the DSM-5 just being released. It’s still not comprehensive. There are political battles amongst researchers as to what goes in and doesn’t to the DSM. I don’t have a particular dog in the fight, but many people do.


The Gray Area

So then comes knowing what’s not in the book. And that moves into the area of a broader bipolar spectrum (rather than just those two types). In this kind of thinking, more people than you know might be bipolar in some lesser form. So if Bipolar I is times of full mania and times of major depression, and Bipolar II is hypomania, then there must be a Bipolar III. And there is.

I trained at UC San Diego, home to Dr. Hagop Akiskal, a world renowned researcher in mood disorders and proponent of the bipolar spectrum. He would come and sit in my office when I was chief resident and just philosophize about things. It was entertaining. He’s brilliant. Yet I still don’t agree with him on the breadth of the spectrum, as he’s famous for believing more people are bipolar than one would think. He’s known anecdotally to believe that there are telltale signs of being bipolar. Like wearing red shoes. And being married three or more times. So I’m a bit skeptical that the spectrum is as pervasive as Dr. Akiskal believes. But it’s worth elaborating on the spectrum a little more.

Bipolar III applies to people who’ve never had a manic or hypomanic episode, and as far as anyone knows, have only been depressed. They’ve never been manic and they could go their whole lives without becoming manic or hypomanic. Until they’re treated with an antidepressant. A person with Bipolar III gets hypomanic only when treated with an antidepressant. This is believed to reveal a special kind of vulnerability to mood swings, and necessitates an approach requiring a mood stabilizer. Because treating with just an antidepressant wouldn’t work, but just switch them into a hypomanic state.

Then there’s a host of other “soft” bipolar diagnoses, and even something called “hyperthymic temperament.” Hyperthymic temperament is like half a bipolar, probably based on half the genetic loading of someone with full bipolar. Someone with hyperthymic temperament doesn’t need to sleep much. They’re always a little driven or elevated. They’re generally very productive. They aren’t like the rest of us. Their elevation helps them be productive, rather than impairing. We may even envy them a little bit. But they may have children with full bipolar disorder.

And so as we get softer in the criteria, it becomes clear why it can be hard to tease out the details, especially when someone has an incomplete memory of their life. It’s often about pattern recognition, and getting the right information.

So what really throws a wrench in the works is people with impulse issues. These are problems like anger outbursts, “exploding.” And we come back to Jesse.

All too often I hear “it’s like I go from angry to sad one minute to another… I’m rapid cycling.”

As the DSM defines it, rapid cycling is more like four episodes of cycling in a year. Not every couple of minutes. But those individuals with mood fluctuations during the day, that are extreme and scary to those around must have something. And they do.

For some it may be a manifestation of PTSD, easily being set off by triggers related to prior to traumas. It can be more persistent, though. If it had to have a name, it would fall more into personality. Now personality issues, such as “cluster B” and “Borderline” are legitimate classifications, but in the real world they have often been used as labels for anyone difficult or oppositional, and to undercut any possible legitimacy to complaints. That isn’t always purposeful, but it is unfortunately the result. More on that another time. Briefly, anger outbursts more happen because this is a coping strategy that people develop. They learned it when they were kids. They learned it on the streets. Somewhere. They learned, probably unconsciously, that as a strategy it works to help protect them, or to get them what they want. Maybe it works to keeps others at bay that might trigger anxiety, or fear. More often it’s PTSD related than Bipolar, and yet time and again basic “irritability” or “anger” are getting diagnosed as Bipolar. Maybe it’s still in the gray, but it’s probably off-white. Nowhere near black.

Finally, there’s the reverse engineering diagnosis. This is one Dr. Akiskal and others advocate publicly. Paraphrased – “People with bipolar do better on mood stabilizers,” meaning they have less “mood” fluctuations. People with Borderline Personality Disorder feel calmer on mood stabilizers, therefore it must be a subtype of Bipolar. There are about a dozen holes in that argument, starting with some mood stabilizers help people to feel calmer, regardless of their diagnosis. Response to a mood stabilizer is NOT diagnostic of bipolar, since many of the drugs work in multiple ways (including as anti-seizure medications).

Who cares?

So when we’re thinking about Bipolar, what does the label matter?

For me, the clinician, it matters in labeling because I need to know what approach to take. If I really think it’s Bipolar I or II, I might only use mood stabilizers and avoid SSRI’s. SSRI’s are very very good at helping anxiety, PTSD, irritability. Calling it Bipolar means we shouldn’t use an SSRI alone, and if it’s really PTSD, that’s just plain wrong. More often than not, we discuss whether an SSRI might be worth a try, recognizing the risks. Furthermore therapy can be neglected when we label everything as Bipolar. As if biologic reductionism is effective in teaching people how to live in the real world. Again, a diagnosis can be used to excuse behavior, which ultimately impairs the person more in the long run.

Well for many people, being able to say they have Bipolar gives them an explanation for their problems. It justifies their struggle or their other problems (maybe PTSD doesn’t show the amount of difficulties they’ve had in life). For others, again, it’s an excuse for “bad” (socially inappropriate) behavior. Therefore the person you meet who wears their Bipolar badge might be very invested in it. Challenging that might not help them. Acceptance without enabling is good. Because even if it is the straightforward Bipolar I, there’s well established effective treatment.  “Mood swings” from depression to normal is depression, not bipolar.  It’s just that Bipolar sounds worse, y’know?

Jesse doesn’t fit the diagnosis of Bipolar.  He might still feel calmer on a mood stabilizer (like lithium or depakote), but that isn’t really addressing why he’s triggered the way he is.  But medications might give him a slightly longer fuse, and breathing room to work on it in other ways.  Again, it’s not that people with these other issues aren’t suffering or struggling.  They absolutely are.  It’s just that using the term Bipolar for all of them just muddies the waters of diagnosis, and ultimately doesn’t serve them as much as we wish it did.

What’s left out here?

Tons. Pediatric Bipolar. Substance use (meth, cocaine, others) inducing mood changes. Psychosis. Schizoaffective disorder. Anxiety.  Why and how we use drugs to treat mood states. All in coming posts…







Well maybe it’s like physics. Kinda.

I was at a party once of non-medical people. A woman we’ll call Jill comes up to me. She’s a teacher, 28 years old, and talks to me about her teaching middle schoolers. I mention what I do, and I get a surprised look.

She’s intrigued, but then brings up all the complaints she’s heard. “My friend went to a psychiatrist, and they were horrible… And isn’t it true that the DSM is run by drug companies?” “So you’re pushing pills all day?” “Why can’t psychiatry figure it out better?”

Where do I start in addressing so many myths? Ultimately it’s hard to convey how difficult this field is.

In fact I hear critiques about my field (psychiatry) all the time. How it’s such a mystery. How it’s a soft science, and wondering why it can’t be more like cardiology. It would be nice for psychiatry and understanding the mind and brain to be finished. Nothing left to learn. But where’s the fun in that?

The truth is that the brain is the most complex “thing” on the planet, and with all we know (which is a lot), we still are only getting started. Mastering the information we do have is still a process, and it’s hard for those outside the field to comprehend how it’s not quite a linear process. It’s hard for them to understand that the brain can’t be understood linearly.

Understanding the mind/brain, as best I can find an analogy, is like learning physics.

At a grade school level, we learn a simple rule: nothing is smaller than an atom. We learn about how molecules are combined atoms, and the way they combine make up everything in the universe. That rule seems straightforward. And at that level it’s absolutely right.

Then as we grow older we learn that that rule wasn’t exactly true, and that really atoms are made of particles called neutrons, protons, and electrons. And the number of these in an atom determines what type of element it is, its weight, its charge, and so on. And we had to unlearn the first rule to accept the next. But in a way the first rule was a good foundation to move to the more complex. It’s easier to first learn about molecules when only thinking about atoms.

Then we continue, and we have to unlearn that electrons are particles. In fact they’re more like clouds, and don’t even exist in one place, but have “probabilities.” But being able to think about them like particles first was useful before unlearning the lesson, in order to understand them relative to protons and the net charge of an atom.

And with each step we learn a rule then unlearn it as we get more complex. Electrons aren’t even clouds, really. And then there’s quarks. And superstring theory. And so on. And it isn’t exactly that each rule was untrue, but just a simplified view was useful for that step of learning, to understand the larger picture, before moving into the more complex and detailed.

So it is with the mind/brain. But even less linear. At an early level is the DSM. It’s a guidebook, and its the best common language to describe illnesses so everyone can have some common language. But even the contributors know its far from the whole picture. It’s a fine starting point, so we can have a reference from which to deviate.

Then with each mental illness there is a body of research literature. Hundreds or thousands of published research papers on an individual topic. Every paper has data, some of it contradictory, that adds to the complexity of the picture. As each of us learns more, we learn to read between the lines in the research, to see some of the bias inherent in different papers. Often the data isn’t even applicable to the real world. Researchers each take different tacks on a specific question or dilemma. I’ll get into this more in future blogs, but suffice it to say that no one take is ever the whole picture. The more sophisticated we get, the better we can recognize which data is useful, and which isn’t.

And then there’s the brain models, from the ways the brain is wired in different conditions, to having larger areas of the brain in some conditions and not others, to more or less neurotransmitters in some conditions in some areas of the brain. And as interesting as it all is it doesn’t tell us enough. It tells us little aside from a hope it’ll pan out to something viable down the road.

Understanding the problem tells you very little as to how to change it. Reading the DSM tells us almost nothing about interventions (meds, therapy). So then comes training and incorporating various ways to actually deal with problems. The process of medication management of problems must incorporate what the pills are approved to do, what they do in addition, and everything else about them (research on them, side effects, how they affect other body systems). And then comes psychotherapy, from learning how to connect to a person, to the myriad of different therapy approaches (behaviorism, psychodynamic, CBT, DBT, IPT, and many many others).

In most ways understanding the mind/brain is not like physics. There’s not higher math. Physics is considered a “harder” science. But they both deal with the mundane, what’s right in front of us, and yet with the intangible. And the more complex aspects of physics and chemistry examine that which can’t be quantified with the senses alone.

So when people complain that the DSM seems incomplete, I agree. And when people tell me about bad psychiatrists, or therapists, I understand why. There’s a lot of information to “master,” and right now we do alright even with just simplistic uses of the information as a minimum.

We’re still looking for our grand unified theory to tie it all together.


But I’m not crazy, right?

“But I’m not crazy, right?”

I get asked this question at least weekly. There’s a person, let’s say twenty years old. Or forty. Or eighty. Or fifteen. Doesn’t really matter the age.  And they’ve reached some point where they’re actually starting to question their own sanity, wondering if they’re about to “lose it.” So they come to someone for help. Are they really at risk? Maybe. If so, it’s probably being driven by the fear itself.

Of course there’s that old colloquialism that if you think you’re crazy, you’re not crazy. That has a grain of truth. One of the biggest issues in actually helping someone change their life or address a problem is getting them to admit that they have a problem. They need insight. Once they have it, the first step has been taken. There’s so many other important steps, though. And that’s really about crossing the threshold to try something different. We each have our normal ways to stay functional. It takes a lot to push us to realize that these normal strategies aren’t working.

The word “crazy” in the question raises a deeper issue of stigma. It’s the fear of “losing it” that may keep someone for far too long from actually seeking any help. And in help I’m not necessarily talking about professional help. That’ll be a distinction I make throughout this blog. People learn through many different paths (hence the blog title), and professional help (with a psychiatrist or other therapist) is one established path. It is not the only one, though. Let me illustrate on a brief tangent.

Borderline Personality Disorder (which will certainly be a topic for many future postings) is a kind of dysfunctional personality that causes a lot of impairment in the individual, but usually prompts treatment because it’s distressing to others. In fact people with borderline PD often get treated because they provoke reactions in others. This might take the form, for example, of a person cutting superficially on their arms, which can be distressing to others to observe. The person watching this happen feels like they can’t watch it any longer, and decided to get them help. Now we have many Evidence Based Treatments for this problem, which are proven to reduce certain symptoms, like cutting (“self-mutilating behavior,” AKA “Non-suicidal Self Injury”). Dialectical Behavioral Therapy, for example, is one of the most popular these days. But this is not the only path to improvement. In older teachings, personality disorders weren’t very treatable. Meds didn’t work. Maybe psychotherapy worked, kinda. Research now shows that when you check in with borderline PD patients later, they got better, maybe even without professional help. More specifically, they had symptom remission, even without having to have aggressive treatment the whole time. Now of course many were in regular outpatient treatment, but it raises a possibility (supported by other research) that even those with severe personality disorders can improve eventually, without aggressive treatment. So maybe these individuals are learning in other ways, from people around them, and it just takes longer for those changes to occur.

So maybe it’s all just a waiting game. For someone feeling out of control, though, part of the fear is it’ll go on forever, or pass the point of no return. Waiting means letting things get worse, or who knows? That’s scary. It’s unknown. There’s a message behind the fear of going crazy, which is really a worry of losing control, in a way that is irreversible. As if once you’re “crazy,” there’s no turning back. It’s a fear of losing a sense of self.

I had a patient a number of years ago, we’ll call him AJ, a young man without anything really unique about his life, who got brought into a psychiatric hospital out of “fear he might do something.” AJ was afraid that he would lose control of himself and do some horrible act that could never be taken back. It’s actually a common fear.

“I think I might lose it and hurt someone in my family.”

He was as normal appearing as anyone, dressed in a button-down and khakis, educated with a college degree, and had been working a regular job as a bank teller. He didn’t have any risk factors that we consider red flags, like a history of violence, drug use, etc.  But job stresses being what they were, he started worrying about his job, and if he might get fired. And he had a scary thought about “what if I did something bad.”  And that thought led to the concern “what kind of person am I that could have such a momentary terrible thought to hurt my family.”  And that led to this snowball effect. The fear of going crazy made him anxious, and being anxious made him feel all the more out of control. Until this all built up to the point that he went to an emergency room. It had taken a long time before he actually sought out any help, avoiding talking to someone out of fear he might be “crazy.” And his avoidance fed the anxiety, until he ended up in an ER. And by that point he had fought it so long he actually was having problems at work. How much easier it would have been to admit that what he was doing wasn’t working. That’s the second hardest step.

Now I’ve seen patients like this quite often, and half the time they’ll get hospitalized by someone to give a level of containment. No one wants to be the psychiatrist that says “OK, this is anxiety, just go home.” Because IF that person (heaven forbid) does something bad (like out of desperation lashes out and hurts someone), we don’t want to be responsible for sending them out of the ER. Sometimes the anxiety is so out of control they might even get misdiagnosed with a psychotic disorder, and end up carrying that diagnosis for a long time. If there was less stigma around mental health, people might seek help sooner.  The unknown and idea of losing self to an illness like schizophrenia is scary.  I’ll touch on that in future posts.  Uncommonly is this anxiety-ridden fear of loss of control driven by legitimate psychosis.  Again, the colloquialism has some truth to it, as most who are legitimately psychotic don’t realize it, at least not in the beginning.

The fear of loss of control fed the anxiety, and the stigma fed that fear. I don’t really like the word crazy. Or “nuts,” or “whackjob.” Or any of that crappy colloquial jargon that perpetuates stigma. I’m not even particularly a fan of “mentally ill.” For some people labels give them a sense of meaning behind their experience, which I think is fine, but it can come at the expense of labeling without explanation, or even externalizing all blame.  “I do this X because I have Y.”

After I’d spent some time with him, determined this was severe anxiety (with panic attacks), and explained it to him, AJ was able to calm down substantially. I started him on medication, taught him some relaxation exercises, and connected him with some therapy options. He had someone outside of himself to normalize things, and give him a way to feel better, quickly. It had a happy outcome.  And yet after he had heard the explanation and the options for treatment and normalizing and all that, he still asked the question – “But I’m not crazy, right?”

Most people will tell you we should decrease the stigma behind mental illness. Aside from awareness and increasing services (I.e. giving more services), few ideas float around. I am equally as concerned though about the increasing prevalence of mental illness (more people being diagnosed as having them). Maybe that’s an artifact of increased awareness, and decreasing stigma, leading to more seeking help. Simultaneously, though, is the very real concern that just more and more is being considered pathological or ill. Indiscriminate diagnosing and ignoring the context of a life may help some people, but in the larger picture causes a whole set of new problems, which now have a life of their own. #Psychiatricmemes that cause new problems, in an attempt to solve others.

No, you’re not crazy. You’re struggling and feeling out of control. Good thing we can help with that.”

[I’m aware I have many soapboxes, and will make attempts to limit the number of tangents per post.]

Coming up next week:
Well am I Bipolar, or not?


Yes, Your Doctor Should Be Blogging

And so it begins…

A new blog. Another amongst thousands. Is there particular utility or reason to follow this one? I’d like to imagine that this will have usefulness to your life. This is more than just thoughts on psychiatry, but really the thoughts of a psychiatrist who is both enamored with and annoyed by his own field. And with modern culture. So everything.

Which raises the question – should a doctor really be blogging? Within medicine there’s a culture of secrecy. We protect our own, not letting on about our problems. Our venues of criticism fall into “peer reviewed journals,” which themselves are prone to problems like publication bias. Those in charge perpetuate thinking in line with their own. Which reflects how medicine functions – by majority opinion. We are expected to practice within the “standard of care,” which is the normal practices of other doctors in our area. Practicing medicine is after all a privilege, granted by the state medical board. Best to not ruffle feathers.

But doctors are not robots. We are people. People who think for ourselves. We’ve gone through four years of medical school and further years of specialty training, and during that we’ve seen through the fallacy of the omniscient physician. We don’t know everything. You can drive a bus through what we don’t know.

And that raises a different responsibility. With all that training comes the ability [probably] to study science critically, to be literate in science and read between the lines. Medicine is not science. It is a craft, or at best an art informed by science. Doctors have the responsibility to use that science as best they can to help others. That may be in a clinical setting, but can also be in public opinion. It’s a social responsibility for doctors to speak up. Pharmaceutical companies and others have their pulpits, funded by much more money than I do. The internet is a venue for others to express their opinions, and it seems a doctor should share his thoughts as much as anyone else.

Now, I know my patients might read this. And showing actual opinions might shatter the neutrality that some choose to believe is necessary in treatment, especially in psychotherapy. Patch Adams challenged that, amidst its flaws. I don’t particularly buy that neutrality is essential to all psychotherapy. In medical circles it’s talked about as “professionalism,” to present a specific image of the profession. That’s fine to be professional. I’m not endorsing sharing personal lives with patients. But the illusion of neutrality should be shattered. At least a little.

I ran into a patient at the gym the other day. He didn’t know I saw him. But if he did it shouldn’t matter. I have to hope he’d respect my expertise even if he saw me on a weight machine. Then maybe we can all start having more real conversations.

I’ll be writing about my thoughts on the field of psychiatry, on medicine, and on challenging the idea that any one view is the most valid. Hence the quote and title of the blog, which is as applicable to medicine as it is to religion, or anything else.

“There are [at least] 21 paths to the top of the mountain. If anyone says he is on THE path, he isn’t even on the mountain.”

Stay tuned.

Paul R. Puri, MD


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