Resetting the Bar

I’m not a fan of competition. It brings out the worst in people, while trying to bring out the best. So of course I have difficulty understanding athletes using steroids or doping just to win a contest. These drugs have possible health consequences after all. For the athlete, I’m sure they believe it’s about achievement and maximized potential, but it’s driven by trying to be better than the other guy. The bar is set by another person.

With that drive they are willing to do “whatever it takes.” Train more. Work harder. We as spectators encourage it and set up an environment that doesn’t reward holding back. Those that hold back anything that might enhance their performance don’t last too long in competitive sports. Once someone else becomes the standard to be matched or exceeded, they determine the bar for “normal.” Anything less is unacceptable.

In society we have a name for functioning below the level of “normal.” We call it impairment. As a psychiatrist I am supposed to intervene when someone has a mental impairment. Physicians usually define normal as the range of functioning of the average person in society. Not having enough energy to get regular activities done is an impairment. As society pushes people to pursue one’s “full potential,” expectations shift up for “normal.” People view normal by unnaturally high standards, and feel disappointment if they don’t meet it. Performance enhancement becomes common, normal, and expected.

When I was twenty-two years old, I did my job with five hours sleep and little to eat. That was normal then. Now in my thirties I need three cups of coffee to get the same amount of work done if I’m sleep deprived. I view it as necessary and justified since the work needs to get done. It’s normal. In medicine we’ve trained ourselves to maximize functioning without sleep, because it’s expected of us.

While it’s possible that my medical training has skewed my view of athletes, college students don’t seem to find performance-enhancing drugs in athletes acceptable either. Last year, in a study in the journal Psychology of Addictive Behaviors, authors Dodge et al., found that college students viewed such athletes as “cheaters.” These same college students, though, believed it was all right to abuse stimulant medications (not prescribed) to do better academically. They did not consider that misuse of stimulants to be cheating. The more they themselves had abused stimulants, the more judgmental they felt about athletes. Stimulant abuse is rampant in colleges, with students attempting to enhance their academic performance. If their classmates are using them and scoring better on tests, the bar is raised, and a new “normal” is set.

I routinely have patients who come to me asking if they have ADHD. More of the time they insist that they have it. They insist because they’re sure they have attention problems. Or because they tried their friend’s Adderall and were “able to focus so much better.” In their minds, improvement on a drug must indicate a diagnosis and thus an explanation for the difficulties. I even have parents of patients who presume that the lack of A’s must indicate ADHD and insist on my prescribing stimulants. Two hundred years ago people weren’t expected to sit in a chair for eight hours a day. Today we have a diagnostic construct of ADHD. Now this isn’t to say to that ADHD doesn’t exist, as we have all seen children who really struggle with this condition.  But perhaps thinking about our expectations reveals the slippery slope that leads to overdiagnosis.

As we’ve stumbled upon many ways to “enhance” functioning, to maximize what we can do with our bodies and minds, the bar shifted on normal. We expect people to perform at that new level. If they can’t, it must indicate a deficit. Such a progression leads to less and less tolerance for any impairment, distress, or problem. In the end, this is really about performance at all costs, masked in the pretense of “treatment.” In 2008 a group of eminent scientists published a commentary in the journal Nature, calling for regulation to allow “cognitive enhancers,” namely open use of stimulants to improve brain function in the average person. Implicit in their argument is a goal to “call a spade a spade.” In that argument, people use drugs to do better at tasks, so let’s call it what it is. I reserve an opinion on the matter.

It’s easy to have perspective on something we ourselves are not doing. Once we have incorporated it into our routine, we develop rationale to justify it. I can understand how the college student thinks “athletes shouldn’t use drugs to win at sports, but keep your hands off my Adderall.” Personally I believe students shouldn’t use ADHD drugs they aren’t prescribed to do better on tests. It’s wrong for them to misuse drugs just to be able to take tests.

Just don’t take away my coffee. I need my coffee.


Psychotic vs. Psychopathic

They aren’t the same. Going back to at least Hitchcock (one of my faves), who brought the muddy term “psycho” into the public psyche, conflated the definitions as if all are violent, and all “crazy” is crazy.

I’m sure there are briefer answers out there for those wondering what’s the difference between psychotic and psychopathic. And even though SRSLY made it into the OED because of its widespread use, lay inaccurate uses of the term psychotic will likely not.

Briefly in discussing how we got here, the words are interchanged because they sound alike, and are used commonly to describe someone “out of control,” often in an unpredictable or dangerous way.  In a way that is accurate for both.

Psychotic refers to someone who has detached from reality in a severe way that the common person would believe they are ill. Common examples of psychotic disorders include schizophrenia, schizoaffective (kind of schizophrenia and bipolar in one). People with psychosis can have hallucinations (hearing or seeing things that aren’t there), delusions (believing things that are known to be false or fantastical, like aliens are controlling their mind through a chip), paranoia (belief others might be following or trying to hurt them), magical thinking (believing they have special powers or could control things that they cannot), or ideas of reference (believing TV or commercials has special messages inlaid just for them personally). Now there are some mimics for any of these, so a single symptom shouldn’t be taken as proof of a condition, but instead the whole picture examined by a professional. Even then many professionals can get it wrong. We do the best with the information we have available.

People with psychotic disorders seem scary because their break from reality can make them unpredictable. Research evidence is quite mixed as to whether they are more dangerous than anyone else. Aside from some individuals who make headlines in terrible ways, on average they probably are not more dangerous than anyone else.

Psychopathic refers to someone without a conscience, who exists on a spectrum from your con man (self-involved, uses others for own benefit, not prone to violence) to the serial killer (predatory, gets aroused by hurting people physically or causing suffering). Psychopaths are scary because they seemingly have no limits to what they might do, including hurting others, just for their own benefit or enjoyment. If you want a bit more detailed discussion about psychopaths, see my posting here regarding Walter White and Breaking Bad.

Is it possible for someone to be BOTH psychotic and psychopathic? Unfortunately, it is. That raises all kinds of other topics, and I’ll leave that for my fictional writing.

Is being a psychopath a mental illness? That is an area of debate, both between mental health professionals, and between government/social services individuals and mental health professionals. Attributing it to an illness lessens the idea of culpability and choice, and directs thinking towards treatment and rehabilitation (of which there is little evidence that much works, though there are some small projects out there that might). Not attributing it to a mental illness or even acknowledging the lack of treatment options means the intervention of choice is containment (usually in prison), which raises all kinds of larger questions – should it be the crime that leads to containment? Can professionals feasibly identify psychopaths and identify those who can’t improve? A lot of controversy has arisen regarding the overuse of the PCL-R (a tool used to measure psychopathy), and that misidentified people might be incarcerated indefinitely. The UK has had an interesting experiment with all of this, with the government wanting psychiatrists to treat dangerous individuals with personality disorders. The psychiatrists didn’t want to do it, so the government forced the issue, creating their own name of DSPD (Dangerous and Severe Personality Disorder), and mandating that psychiatrists intervene. It’s an interesting social experiment, and continues to raise questions and controversy.


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.


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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