WillSpirit!

Where Will meets Spirit
∞ Love, Clarity, Balance, Peace, & Bliss ∞

A science, mental health and spirituality blog written by a physician.








  • Red_Exclamation_DotDisclaimer
    • Dear Visitors:
      Although I trained and practiced as a physician, my background does not include formal instruction in psychiatry beyond basic medical education. This journal presents ideas about treatment philosophy, but must not be considered therapeutic advice. Abrupt changes in one's psychiatric medications can trigger profound cognitive, emotional, and physical symptoms, including suicidal thoughts and actions. Consequently, pharmaceutical agents should not be increased or decreased without supervision by a mental health clinician.

    • ON THE OTHER HAND, your brain belongs to you, and your opinion counts. If you decide that changing your medication regimen will serve your best interest, then I believe your providers have an obligation to help you try to achieve your goals. I want everyone to be educated about their options, and do what will be most helpful for themselves. No one should feel pushed around by dogmatic and/or limited viewpoints, whether those of psychiatrists, anti-psychiatry advocates, or myself.


“Let ‘em jump”

GGBridge

In an email, a reader suggested I take up the subject of the murderous army psychiatrist in Texas. I had not paid much attention to the awful tragedy; I find it helps me little to follow such events. In fact, I get demoralized thinking about the wretched state of modern culture, where fallible humans can handle weapons capable of wiping out dozens of lives in just a few minutes. The first news reports, to the extent I could not avoid the headlines, seemed to indicate the guy ‘snapped’ because of impending deployment to Iraq. That would have made a more interesting and less inflammatory subject, but now there are suggestions he had ties to Muslim extremists. Predictably, that possibility has summoned the nastiness out of the rotting foundation of this country’s democracy. A senator from Illinois is blaming Barak Obama, because the President’s father was Muslim. His comment lacks honor, like much of what I hear today. Regardless of how one feels about the leader of this nation, accusing him of causing this nightmare is simply silly and opportunist. But this is not a political blog, thank God. Since it’s so sparsely read, I imagine I can get away with the fractious sentiment I just inserted. But I’ll say no more along those lines.

That a psychiatrist committed such an act, and that there is at least a suggestion he did it because of mental stress, is interesting to me for other reasons. In general, people do not expect well-educated, successful, established doctors to lose their grip. I was once insane (technically, ‘psychotic’.) And I was once a physician. Unless you count depression as delusional, I was never out of touch with reality and practicing medicine at the same time. The point, however, is that lots of training and responsibility are no insurance against insanity. (Whether this particular psychiatrist lost contact with reality, or committed insane acts with full awareness of the humanity of those he was killing, is immaterial to my point. Either way, he quit acting in a rational fashion—and I would hold that to be true even if he killed because of extremism.) Mental illness, unlike humanity, does not discriminate. All races, classes, occupations, genders, and ages can be struck by it. Yes, the psychiatrically disordered as a group have less-than-average income and living standards, but poverty is more often an effect than a cause of psychiatric conditions.

Not very long ago, I tried to become a psychiatrist (I also applied to PhD and master’s programs in psychology;) this was back when I still sought a ‘secure’ career. Now I am only interested in writing, and can be free in what I reveal about myself. But when I was still interested in working as a clinician, being open was a risk. And I was too open in my applications. Foolishly, I thought having a life history saturated with family and personal mental health problems made me a better candidate. I thought the admissions committees would recognize my increased empathy toward patients, and better understanding of their situations. Instead, I was told I showed ‘lack of boundaries,’ and demonstrated ‘too much self-disclosure,’ to be a successful applicant. Personally, I think this was code that told me they did not want to knowingly accept someone with a history of psychosis, however remote and circumscribed it was. At the time, I felt furious. Friends encouraged me to launch anti-discrimination lawsuits. Obviously, the programs did not want to accept a psychiatry resident who might go on to, for instance, fire upon dozens of people at an army base. My belief is that they could have looked at the utter absence of violence in my story, and seen that a childlike conviction that God walked beside me was fundamentally different from being lost in a homicidal obsession. Or that a single event many years ago, one prompted by an antidepressant drug, did not put me in the mass-murderer category.

There is such fear of mental illness, however, that no one wants to take responsibility for making such distinctions. It’s easier to just be cautious and say ‘NO.’ I encountered the same roadblock at Big Brothers, Big Sisters. After a long vetting process, including interviews and fingerprinting, the director of our local chapter told me they could not accept me because of my psychosis history. I don’t think the guy even knew the precise meaning of the word, ‘psychosis;’ it was just too scary and seemingly too risky for him to accept. I thought the way I’ve overcome a stormy upbringing, broken family, history of child abuse, and so on, would help me be a good mentor to a troubled youth. But by being honest, and admitting my psychiatric problems, I ruined my chances.

I understand better than before why many African-Americans are burdened with chronic anger. It is maddening and humiliating to have people judge you on the basis of category rather than capability. To have skin that is brownish rather than pinkish, and so be out of the running regardless of who you really are, must be an excruciating experience. Fortunately, overt racism is no longer tolerated. But the historical memory, and covert discrimination, will continue to harm for a long time.

There is little societal proscription against discrimination on the basis of mental illness. There are laws, but people ignore them. Few seem to think twice before making jokes about ‘crazies.’ A few days ago I was drifting (there was almost no wind) in a sailboat under the Golden Gate Bridge. The group I was with had been put together through an online social network. I did not know any of them. Naturally, at some point people asked me what I ‘do’ for a living. The answer is complicated, but mainly I write. Not for a living, but as an occupation and with a tiny prayer of someday making money. The next question, ‘what do you write about,’ brought us to the topic of mental illness. With my usual lack of boundaries (vide supra,) I told people that my interest in the subject started around the time my mother killed herself.

An hour later, when we approached the Golden Gate Bridge, someone brought up the fact that plans are in place to put a net underneath to curtail the frequent suicides (which average two a month.) One enlightened sailor retorted, “Aw, just let ‘em all jump!”

I was too shocked to respond at first. Was he being deliberately cruel to me, after what I said about my mom? Or was he just ignorant and rude? By the time I organized a response, the conversation had moved on. I tried to bring it up again, but someone changed the subject before I got too far. So I gave up, and came home feeling very different from ‘normal’ people.

I started this post with the intention of writing about how despair and mental illness can strike anyone. I ended up talking about discrimination. Both are important subjects, but I find writing about them in this direct way less engaging than my more emotionally immediate pieces. The best solution to ignorance and prejudice is to enlighten others by putting human and close-to-home faces on psychiatric conditions. That is the direction I am hoping to go with my writing. Not addressing discrimination in exposition, like I just did, but by helping others glimpse the inner landscape of mental distress. My hope is that I can help people who, like me, battle psychic demons. I also pray that I can move people who think they are ‘normal,’ and harbor hostile attitudes about mental illness, to adopt a more compassionate stance.

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Insomnia, and other underrated forms of madness

brainasleepanatomy

One manifestation of my brain’s atypicality can be seen by tracking my sleep patterns. Over about a six day cycle, I regularly drift from spending about nine hours asleep to getting only three hours a night. It averages out to six hours per twenty-four, which is not bad, but it’s hard to maintain a sense of predictability and regularity with this pattern. Also, sometimes around 8:30 pm I feel worn out to the point that I can’t stop myself from going to bed early, but then I wake up after midnight, like I have now, and remain awake for four or five hours. After that I’ll go back to bed and (hopefully) sleep for another hour or two. Over the years I’ve tried many things to smooth out this roller-coaster, but to no avail. I don’t want to take sleeping medications 50% of the time, which is what I would need to avoid the three-hours-of-sleep nights. And if I try to stay awake when I’m tempted to tuck in early, I find my mood sinks so low that nothing gets done except sitting and brooding. Or watching TV and dozing off. Reading and writing just don’t happen when I feel that way.

I try to take advantage of the nights I don’t sleep. I write or study or meditate. If I’m at our Yosemite place, I may sit in the hot tub and marvel at the stars (so many stars up there in those primordially dark skies). Now that I take fewer psychiatric medications, I see that I need even less sleep. As humans age, some data suggests they tend to sleep fewer hours (there is better evidence that the proportion of time in REM sleep decreases). Since I started out not requiring much more than six hours, it’s beginning to look like I’ll end up needing only five.

What is sleep doing for us, anyway? In what I’ve read, and it’s not extensive, the answer is clear: no one knows.

One popular idea is that it helps consolidate memories. Experiments with sleep deprivation after certain types of learning tasks back this up. In particular Rapid Eye Movement (REM) sleep seems connected with acquiring new skills. When people sleep after learning complex tasks, brain imaging sometimes shows that the same regions are active during REM sleep as were active when the task was being practiced. This seems to suggest that REM is replaying the learned activity, presumably in order to fix it in the mind.

On the other hand, although facility at learning tasks (technically called ‘procedural memory’) associates with sleep, the ease of learning information (‘declarative memory’) does not. And even if REM helps some forms of memory formation, that does not explain the need for all the other stages of sleep (and there are several).

Although I like to understand the brain, I am happy that there remain so many mysteries. My suspicion is that this will be the case for a long time, possibly forever. The organ has such unimaginable complexity that figuring out what it does is truly daunting. Despite all that we’ve learned, we really don’t understand more than some superficial information like which areas demand more blood during which activities, or the types of neurotransmitters that mediate different brain functions. The fine details of how computation (a.k.a. thought) occurs remain quite obscure. Some basic facts have been established. For instance that information processing is modular. This means that incoming visual data get broken down into components such as depth, color, movement, and orientation in space. Each of these are handled by separate (though often adjacent) clumps of nerve tissue, and later recombined. But computational studies remain coarse in the level of activity they investigate: typically the combined signals of hundreds of simultaneously active cells.

In fairness to the brain science community, I am oversimplifying. Enormous amounts of research have been done. So much has been learned that I really have only vague estimates about how much is known. But I have a pretty good idea about what is not understood: i.e., most of what the brain does.

It is easy to get impressed with the volume of factual information about the brain that scientists have collected in the past one hundred years. But it is even easier (and more important) to get a sense of awe from the realization that despite all the millions of pages written about the brain, we really don’t know something as basic as why sleep evolved.

Psychiatrists, and those who consult with them, would do well to keep this in mind as they try to address complex personal issues (like excessive worrying, chronic sadness, or uneven sleep) by adding one or a few chemicals to the blood stream. These solutes reach every cell in the brain, and affect many, many more neurons than the ones ‘targeted’. And even in the cells the medications are meant to affect, the actions are varied and all too often transient. The brain is quite adept at restoring its native state (see my post on receptor downregulation).

Sometimes it is better to accept an atypical pattern, like wacky sleep cycles, than to wrestle the brain into normative behavior with drugs. Besides, there can be advantages. Like writing a post in the middle of the night, so tomorrow I can concentrate on the other work of blogging: reading what others write. Or maybe I’ll have time for more fun with Mandy and the dogs. Or a longer workout. If I gave in now and took a sleeping pill, I would spend a nice restful night in bed. But I would wake up tomorrow after too many hours asleep, and still feel groggy. And if I kept taking the pill night after night, pretty soon my sleep would be dependent on the drug. If I stopped it, I would face several nights of near-total insomnia before I got back to what my brain wants: a six day rotation between nine hours and three hours of sleep.

I don’t know what this says about my brain’s health. It would be easy to call the three-hour nights ‘hypomanic’. In fact, I used to live in fear of them, thinking that hypomania meant possible manic loss-of-control and/or inevitable subsequent depression. Now I find that is not true. Provided I always allow myself to sleep when I can, and make sure that even if I can’t sleep I get some time in bed resting and calming my thoughts, I do pretty well. I don’t find myself making horrible decisions, or getting pounded by despairing feelings of worthlessness and futility. Admittedly, in my life I have seldom had true manic episodes (maybe only one time, but it lasted 2 years and destroyed my life). So I don’t worry too much about completely ‘losing it’, and (for instance) gambling away my life savings. But I know some who do have more trouble with severe mania, who find they can manage it with less or no medication, provided they are diligent and committed to keeping things healthy. It helps to have a devoted and observant spouse.

Society exerts pressure on people to conform. That becomes obvious in grade school, and it never changes. The main body of humanity tugs hard on the fringes, trying to pull them into the huddled center. Deviance, or even disagreement, tend to be poorly tolerated. So those of us with brains that function ‘differently’ from the ones comfortably in the center of the bell curve have to contend with criticism, rejection, and pressure to take drugs. All are either indirect or direct efforts to get us to conform.

There are mental states that pose hazards. Particularly to the individual who suffers them (i.e., suicide), and more rarely to others (e.g., the family left bankrupt by a manic run to a casino, or the spouse broken-hearted by a string of impulsive and dangerous sexual liaisons). The tiny threat of physical violence against strangers (the ‘psycho’ murdering students with an assault weapon), gets a great deal of attention. But if we define wanton violence as pathological (which I’m not saying is a bad idea), then many heads of state should be diagnosed as ill. If we go a step further, and say all those with a propensity for needlessly harming others require pharmacologic therapy, then we really should have force fed George W. Bush with Seroquel.

I’m not saying that no one should get psychiatric medications. That is not my position. But it is all-too-clear they are overused, that they cause physical and mental anguish, and that they are not particularly effective (unless you count drugging someone into a slurred stupor a success). The pharmaceutical companies have had free reign to promote their product, and we need to rise up and apply counter-promotion to balance the scales.

insomnia

In a larger sense, it is vital that we stand against the shove of society, and reclaim our right to be different. The tension between those who demand absolute obedience to the dominant culture’s standards, and those who advocate diversity and creativity, is never ending. The first step is to recognize that this is the problem we face. We need to demand to be allowed to be different, and then accept help when we want it. Otherwise we get the current situation, where we are told we are sick, and have to refuse drugs at every turn.

I’ll be up for a while longer. I’ll edit this post, write a letter or two, and explore some of my fellow travelers’s blogs. I’ll appreciate this night of little sleep as a time for making up the lost ground that resulted from weeks of rocky moods while withdrawing from Cymbalta. I’ll be glad I’m different. I’ll claim my privilege to consider myself ‘better’ than the boring norm.

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“A rose by any other name would smell as sweet…”

rose_mosaic

One of the sites I’m fond of is Hopeworks Community. A number of things can appeal to me about a site. Some are heartfelt. Some are lyrical. Some provide pragmatic advice. Some take political stances. In fact, most do all these things. Hopeworks provides reasoned analysis of issues relevant to people affected by mental illness (but see Hopeworks and what I write below for some discussion of the ‘illness’ concept). Any time I get engaged in a topic, my fingers go nuts and before long my text has morphed from an intended sentence or two into a mini-essay. That happened yesterday on Hopeworks, when I wrote a comment discussing two posts: ‘What diagnosis depends on‘, and ‘On the words we use‘. The subjects were diagnosis and semantics in mental illness. Important subjects. Since I was happy with my little response, and since I won’t have much time to write today, I am posting my discussion below.

I promised to write about the relationship between ‘who we are’ and ‘what goes on in our brain’. That topic is so vast that covering it in a blog post is presumptuous to the point of grandiosity. But I do have some ideas that can be squeezed into one of my longish essays. The interrelationship between mind and body (especially, of course, brain) fascinates me, as it has philosophers for ages. I want to do it justice. I have touched on it before, and no doubt I will come back to the subject over and over until the day I die (hopefully a long time from now, for those who monitor me for suicide risk). So the much-anticipated essay will be produced soon. But not today.

Instead, here is my 2¢ about diagnostics and the labels that result.

[Comment to Hopeworks with regard to psychiatric diagnosis:] Having had medical training, and even one-time aspirations to become a psychiatrist, I started out with faith in the DSM. The more time I spend as a patient, and reading blogs, and thinking about how I’m going to get to a better place, I see the fallacy in labeling people as mentally ill. My latest thinking is that our brains are as different as our mugs. Maybe I even brought this up on your blog before. You can categorize faces: male, female, European, African, Asian, old, young, attractive, ugly. And you can separate facial expressions: happy, sad, angry, etc. But just saying someone (like me) is a male, of European descent, middle-aged and with a look of concentration at this moment does not mean that is all I am or will ever be. It is not enough information for you to recognize me on the street, or to know what would work to make me more comfortable with being alive.

Psychiatric diagnoses have that level of precision. Some people have fluctuating moods. Some are chronically sad. Some worry all the time about everything. Some hear voices and have ‘odd’ ideas. Each of these persons can be diagnosed with a DSM label, and so by that definition they are mentally ill.

It’s a bit like saying only a particular race or gender is capable of running things. Only a certain emotional make-up is healthy; deviate far from that norm and you have a disease. Maybe you should be locked up and sterilized. You certainly can’t be in a position of leadership or responsibility (is anyone else old enough to remember Thomas Eagleton?).

Like you say, what matters is what works. And what works is what makes life a more satisfying experience. Dulling emotional responses, or squelching internal voices may help accomplish that for some people. But not for all. Some would be happier to be left with their minds in their native condition. Some can get a lot more happiness out of life by accepting their quirky brains than they ever can by acquiescing to long-term psychiatric drugs.

As someone who once bought the mental disease model intellectually and emotionally, I am astounded to find myself about to write that I am not sure that mental illness is a valid construct. I took all my meds diligently for years (I was a very ‘compliant’ patient). But I still felt rotten. Now I feel better even though I am on a milder chemical cocktail (hopefully soon to be none at all). So was I really sick? Or just confused?

I spend time on the local psychiatric unit, counseling patients about their legal rights when they face involuntary confinement. Some of these people are quite out-of-control, and would have trouble being safe on the streets. I can’t say what the answer is in those cases. Maybe when things go that far there really is a sickness going on. But that does not mean that the person has a mind that can never be trusted again. That they now should carry a lifetime diagnosis of, say, bipolar I. That they will require drugs forever, and can never learn to live safely and well without medication. Maybe it is the all-too-frequent permanence of mental illness diagnoses that is their biggest problem.

We are all different. ‘Some of us are more different than others.’ The problem with the ‘illness’ label, is that it automatically means there is something defective. Maybe all that is wrong is that our eyes are open. That we see and feel more pain, or are more in touch with imaginative influences in our minds. Or we are more conscientious and want everything to be just right. Or impulsive. Or scared. These are not illnesses, they are responses to life. Maybe they are exaggerated and do not serve us well. Maybe medications can help us live fuller lives. But I object to being told my brain is abnormal, and that the person who never soars into ecstasy or crashes into sadness is healthier and (by implication) better.

It cannot be overstated: what matters is what works. If having a diagnosis in hand makes one feel vindicated, so now they can show people they aren’t just lazy or selfishly pessimistic, then it is a good thing. If it helps select a medication to get someone balanced enough that they can go home and work on better solutions, then maybe a diagnosis is useful. The same if being given a name of their ‘lllness’ leads a person to the most helpful shelf in the bookstore. But if it means I can never get long-term care insurance (I can’t), or be trusted to practice medicine (a psychiatry program I applied to reported me to the medical board), or that I will always need to take medications that wreck my body and undermine my self-image, then they are most definitely not OK. thornsThat kind of thing happens so often, that it is easy to understand why people with mental/ emotional/ behavioral/ brain/ psychiatric – illnesses/ conditions/ disorders/ diseases/ abnormalities/ challenges/ dysfunction/ gifts object to the psychiatric model. When diagnostics work they help a little. But when they are overused, misinterpreted, or otherwise go awry, they do an incredible amount of harm.


(I slightly modified this post on 2009 August 17, c. 08:30 PDT.)

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