Please, somebody wake me up and tell me I’ve been having a bad dream. I didn’t just read that the District Attorney in Collin County has charged a Plano woman, Dena Schlosser, with capital murder. She can be put to death for taking a phrase in the Bible literally and cutting off her baby’s arms. It couldn’t also be true that Child Protective Services is not letting her husband have his other two traumatized, confused kids for just the opposite reason. He didn’t take his wife literally when she told him the night before the incident that she was giving the baby to God. He is being punished because he didn’t know his wife was insane before she carried out an obviously psychotic act. But the district attorney hasn’t figured it out, even after the act.

The reason I know that I’m dreaming is that this is 2004. Our government officials couldn’t be that obtuse. How could they expect the husband to take his wife literally? Even in the Bible, when Samuel’s mother said she was giving her son to God, she meant she was dedicating his life to God’s work. I guess if the CPS officials came to a fork in the road – they would eat with it.

Our officials need to make up their minds. They can’t have it both ways. You can’t expect the wife to think metaphorically and the husband to think literally. As a New York newspaper chief editor (and crusty Texan) told his fence riding journalist, "Don’t pee down both legs at the same time." So what’s the problem? The problem is the law is out of touch with reality. I guess you could say the law is not sane. According to the law, there are two options – guilty OR not guilty by reason of insanity. But she IS guilty. She is guilty by reason of insanity.

Scott Peterson is a totally different story. He is obviously guilty by reason of severe narcissism and sociopathy. He has no conscience. Mrs. Schlosser, Andrea Yates, plus another woman in East Texas last year were all suffering from postpartum psychosis. 

The percent of women who become clinically depressed in the few weeks after having a baby is ironically higher than at any time in a woman’s life. Fortunately, psychosis during this period is not common. It only occurs in about 1 in 1000 deliveries. Most of the time, women who develop postpartum psychosis turn out to be bipolar. This is a serious mood disorder that requires continuous treatment, just as does diabetes.

Most women who develop postpartum psychosis don’t murder their babies, but it is a well known possible complication. Most of the time, women who murder their babies lack adequate family network, have husbands who don’t provide enough emotional comforting, and they are usually involved in a fundamentalist church.

One classic symptom of psychosis is concrete thinking (i.e. taking everything literally). Have you ever had a really crazy dream? That’s the way the psychotic mind works when they are awake – and to them it seems real.

Fortunately, we have excellent medications to treat this disorder. Unfortunately, these medications are expensive and our "managed cost" medical system often only provides less expensive, less effective medication. 

Let’s wake up from the dark ages. I believe the United States is the only country that treats infanticide during postpartum psychosis as a crime. Scott Peterson murdered his wife and unborn child because he didn’t want to be bothered by a child or child support. He planned it out carefully and tried to hide the fact from everyone. Dena Schlosser and Andrea Yates murdered their babies to send them to heaven. They immediately called someone to tell them what they had done. Am I crazy or do these two scenarios seem different?

Guilty by reason of insanity!

They are the best of times and the worst of times, to borrow a phrase from Dickens. Parties, presents, family – and parties, presents and family.

Why do so many people feel so much stress this time of year? Parties are fun to go to – mostly, but then there’s the pressure to make small talk, the gossip, the time, and if you’re giving the party – the planning, shopping, cost and clean up. For many people who have social anxiety, they are especially difficult.

Then there’s the gift buying – what to buy – how much to spend. Thank God for plastic – until you get the bills. There’s the traffic, crowds, and an overwhelming amount of crap, frequently on sale and still usually overpriced. But the main stress of the holidays for many people is the family. Every day in my office I hear some horror story about some blow-out at a family function. In a recent interview, Donald Trump said "Friends are great; family is greater" – or not, I might add.

Why does there seem to be much more resentment between family members than between friends? What exactly does "blood is thicker than water" mean? It is certainly messier when it’s spilled all over the place.

The greater risk of hostility occurring in families has multiple causes. First, there’s a greater likelihood that we will get together with people we don’t particularly like when we are related to them. Many people avoid confrontation or open discussion of conflicts. In family, this may result in smoldering hurts and resentments, sometimes for decades.

Second are many opportunities for envy or jealousy. Third are feelings of entitlement that inevitably lead to disappointment. Fourth is a greater likelihood of indulging ourselves with a temper tantrum or tirade that would be fatal to a typical friendship but are usually tolerated in the context of the family. Throw in alcohol and the added stress of rug rats running around everywhere and you have the recipe for potential disaster.

What can we do to protect ourselves – or at least lessen the risks?

There’s no such thing as an unexpressed feeling. If not expressed or dealt with openly, it will come out indirectly in some neurotic or passive aggressive communication or will be internalized as a somatic or physical symptom.

But feelings don’t have to be expressed immediately. It’s OK to wait until a suitable time and place. The holidays aren’t the ideal time to try and resolve ongoing conflicts. Anticipating an awkward situation and getting together ahead of time to clear the air is preferable, if circumstances allow. But if not, it may be helpful to let the person know that you’re aware of the problem and that you would like to get together soon and talk (set a specific time if possible).

When you have a "serious talk," set your goals realistically. It takes two people to have a positive personal dialogue. It also takes two people to have a nasty fight – Either one can usually stop a bad exchange. Sometimes the best you can do is acknowledge that you understand how the other person feels and why. You don’t have to agree. You can’t make them understand how you’re feeling, but you have a better chance once they know you have heard their position. Covey says in Habit 5, "Seek first to understand, then to be understood."

The pain of lost loved ones is frequently most intense during the holidays. It helps to share feelings and memories with people you are close to. Don’t just share how much you miss them and how it’s not the same without them. Recall the happy or especially funny incidents. Be thankful you have loving memories.

Listen with your "third ear," to paraphrase Theodore Reik. Read body language and tone of voice so that you might prevent gradual escalation to an emotional uproar. When appropriate, use active listening. Point out the feeling that you sense (i.e. "You seem quiet or down or upset or stressed."). This invites the other person to share. If sincere, be supportive, but other options include getting an agreement that prevents an increase in tension. Be caring, playful or straightforward. Do not be critical, controlling or sarcastic.

Try to avoid feeling sorry for yourself, even if you inherited a screwed up family. Don’t be a rescuer and try to fix everything. We can observe a lot by watching according to Yogi Berra. And Einstein said, "Insanity is doing the same thing over and over and expecting a different result." Do something different.

For the fortunate, the holidays are the best time of year. We get to see our families, participate in traditional activities and laugh a lot. If you are not so fortunate, don’t be part of the problem. Be part of the solution. You can start a new tradition this year.

Good luck!

Many studies show that stress symptoms and disorders are increasing. Not only are more people becoming clinically depressed, but it’s starting at an earlier age. Suicide is second only to accidents in cause of death in teenagers. The average adult weighs 30 pounds more than in 1970. Stress is a major contributor to complaints of fatigue, headaches, anxiety, insomnia, poor concentration, lack of interest in sex, digestive problems, and high blood pressure. The list goes on and on.

You can think of stress symptoms as being like debts in your STRESS ECONOMY. IF your deposits (stress management) are less than your withdrawals (stress), this creates stress overload. Sometimes symptoms are caused by too many concurrent pressures (changes) but other times by a decrease in stress management.

A man came to me complaining of recent onset of panic attacks. He seemed to have everything going for him. He was in good general health, was financially well off, and had a great marriage. BUT, he did have a high volume business in a competitive market.

My assessment of why he suddenly started having symptoms is that he had stopped his daily thirty minute jog. He had fallen while working on a home improvement project and was a walking cast. Many people who don’t have any symptoms are susceptible to one sudden change or loss pushing them over the line and out of balance.

Selye defined stress as “the wear and tear of life” or, more specifically, that which increases your Cortisol (stress hormone).

If I had to put one word between life’s stresses and illness it would be Cortisol. Cortisol is essential for life. In a crisis Cortisol “marshals your troops to the front line” – BUT at the expense of longer term concerns like your immune system and less essential functions in an emergency, like digestion and sexual functioning. Chronic stress overload suppresses your immune system. This means not only increase in susceptibility to infection but can ultimately cause cancer that may not become symptomatic and diagnosed until years later. A study of dental students found that wounds took 40% longer to heal before exams than before the semester started and that their immune function before exams was reduced by 2/3′s. Stressors can be obvious. Travel is more difficult since 9-11. We all have some level of concern about the dangers associated with terrorism. But there’s the more mundane – traffic, deadlines, tests, conflicts, health insurance – an almost endless list of external issues that are far more complex than ever in history. There are also internal stressors – attitudes and expectations that we have. We put pressure on ourselves, and we sometimes dwell on past mistakes or worry excessively about the future.

More important than stressors themselves is how much control we have. When mice were experimentally shocked until they pressed a certain lever, and this was repeated over and over, they did not show much elevation in Cortisol. But when these mice are connected to a 2nd group of mice, who don’t have the levers but get exactly the same amount of shock as the 1st group, the 2nd group (without the levers) become agitated initially, but then give up and become passive. Their Cortisol levels are extremely elevated. Being helpless is more stressing than being shocked. It also shows that chronic stress eventually leads to exhaustion and fatigue. If the 2nd group of mice is given access to levers after they have reached this last stage, they don’t even try to use them. This has been called “learned helplessness” by Seligman. In today’s highly complex society, we have much less control than our ancestors. I remember a tax law change that lowered the value of the office condo I owned by 80%. Seventeen years later, it’s still worth only 1/2 of what I paid for it. Stress!

Another factor that alters the the effect of a stressor is predictability. Studies done with primates by Coplan dramatically demonstrate this. New mothers were put in one of 3 situations relative to getting food for themselves and their babies.

Food was either easily available, or required hard work and looking, or it varied between the two conditions. The mothers in the unpredictable situation became highly stressed. Importantly, so did their babies. Most importantly, these babies grew up to become adults who had permanent vulnerability to stress.

This study has also documented the effects on the brain of the stress syndrome. They had much lower survival rates of new brain cells, especially those in rapid access memory part of the brain.

There are other factors that influence how we react to stress.

• Genetics – animals can be bred to be overreactive to stress or to be highly resilient and less than average in their stress responses.
• Gender (sex) – women between puberty and menopause are more reactive to stress than men. When asked to dwell on the worst experience of their life, women had 8x’s more activity in the areas of emotional processing in the brain as men doing the same exercise. After 9-11, men were angry and increased their physical activity. Women were more emotional, worried about their loved ones, and had more symptoms.

One of the most important determinants of stress reactivity is early life experience. Even in utero, the fetus is impacted by the mothers stress symptoms. Clinical depression during pregnancy increases stress vulnerability in the infant and this effect is long lasting. One of the most controllable factors in stress reactivity is clinical depression itself. Stress reactivity, more than stress itself, determines response. Early recognition and adequate treatment to full remission is protective.

Just as physical exercise can make you stronger, manageable stress makes you more resilient. Animal studies show that brief separations of babies from their mothers followed by nurturing led to resistance to adversity. This has been called “Stress Inoculation”.

The following will also help reduce stress symptoms:

1.  Get rid of unnecessary stresses

2.  Resolve ongoing disputes

3.  Be proactive

4.  Attend church or have a spiritual life

5.  Have strong relationships and social support

6.  Have a good sex life

7.  Be physically active

8.  Get at least 7 hours of quality sleep per night

Last week, a rep from a pharmaceutical company that manufacture a sleep medication was in my office.  He said, “You have a unique practice because you see a lot of patients with sleep problems.” I said, “WRONG! I see the same patients that all psychiatrists and primary care doctors see. The problem is most patients that have sleep problems don’t mention it to their doctors, and unfortunately, most doctors don’t ask.”

I believe all patients need to be screened for all common, treatable problems every visit.

Sleep is the first thing I ask about on my screening questionnaire. Two days ago I was seeing a patient who happened to be the wife of a primary care physician. She told me recently her internist put her on Prozac for anxiety and depression. She immediately developed a significant sleep problem as a side effect. She asked him for a prescription for Ambien. He told her he didn’t prescribe Ambien because it is “highly addictive,” but she could take Benadryl. (See previous discussion on “pre-extraction disorder” P.E.D.) There are several problems with her internist’s response. First, Ambien isn’t addictive at all. An occasional patient will develop a mild physical dependence after several months of nightly use, but physical dependence is a physiologic adaptation and has “nothing to do with addiction.” This is not just my opinion but that of Dr. Robert DuPont, the first director of the National Institute on Drug Abuse. Fifteen percent of patients taking Ambien for one year every night will have one to two nights rebound insomnia if they stop it abruptly. This is hardly addiction.

Addiction is compulsive use or behavior in spite of negative consequences.

The second problem with her internist’s recommendation is that Benadryl is a horrible sleep medicine. There’s no scientific evidence that it’s effective. It doesn’t provide normal sleep (Stage IV deep sleep and dream sleep), and it frequently leaves you with a hangover. Other than that, it was a great idea. The third, and most important problem with his recommendation was that his ignorance with regards to the importance of a good night sleep.  The effect of sleep loss was studied in healthy young men awakened after 5 hours of sleep.  After just one night, they showed decreased concentration, marked irritability and increased levels of cortisol, a stress hormone that suppresses normal immune function and contributes to abdominal weight gain.

I consider good sleep (7-8 hours) the most important part of stress management.

Longevity studies show that too much sleep is actually worse than not enough. In the short term, excess sleep drains mental energy. A national survey found that 10% of people have a chronic nightly sleep problem, but 2/3 of the adult population has at least occasional sleep problems.  The good news is that we have effective, safe medications that provide normal sleep and are totally out of your system in 5-8 hours.  The bad news is many doctors are afraid to prescribe them and most people don’t have access to them. 

I think every home needs to have Tylenol and a good sleep medicine on hand.

Most people need to have a good sleep medicine (Ambien, Sonata, Lunesta).  We weren’t made for this world. We adapted from 1000′s of years in a world where we were outside and physically active all day.  The bright sunlight regulated our sleep, energy, and metabolism. Whereas, now most people are mainly indoors and sedentary. Life use to be hard but simple.  Now, it’s extremely complex and changing at an exponential rate, but we still have the old adaptive mechanisms.  We respond to mental stress with the same flight or fight mentality, but these aren’t appropriate responses to today’s stress.  It’s like driving your car hard all day but not putting it in gear.  It’s not good for your car, and it’s not good for our bodies. We end up hyper aroused, can’t relax and have problems sleeping.  We need a new stress management technology, but right now, the best we can do is great medicines.  It’s just a shame that most people either don’t know about them or can’t get them because our medical system is broken and most doctors just don’t get it.

Several years ago I was speaking in a family practitioners office in Marshall, TX. I started out with a question, "If you were treating President Clinton, what would you prescribe him?"

He immediately answered, "Prozac."

I said, "Good, and that’s because …"

He said, "It causes people to commit suicide."

Of course, I was thinking more along the lines of reducing libido, but he had raised an interesting point.

Does Prozac or other SSRI’s increase the risk of suicide?

The best answer is, usually not. Studies have shown that overall, antidepressants decrease suicide risk. In one large study, patients with depression were twice as likely to commit suicide if they weren’t on antidepressants. So you could say that antidepressants reduce the risk but don’t eliminate it. But, can antidepressants sometimes increase risk? Unfortunately, yes.

How can antidepressants increase suicide risk?

1. Some patients are very sensitive to side effects and become very anxious or agitated on antidepressants, and anxiety is one of the main symptoms associated with acute suicide risk.
2. A second possibility is that a person with depression associated with hopelessness and immobility may be activated enough by the antidepressant to carry out a suicide plan.
3. More common would be a situation where someone is bipolar or at least has bipolar genetics and the antidepressants cause a dysphoric hypomania. This is one of the most suicidal states where someone has symptoms of depression and hypomania at the same time. (see bipolar newsletter for details of these states). Why would it be more of a problem in kids and teens? Because, the earlier the age of significant depression, the more likely they have bipolar genetics.

(1)"In June, the Child and Adolescent Advisory Commitee of the International Society for Bipolar Disorders issued a position statement on antidepressant medications for children and adolescents: ‘they (primary care doctors) should monitor their children for the emergence of specific symptoms that may warrant referral to a psychiatrist: anxiety, agitation, panic attacks, insomnia, irritability, hostility, impulsivity and severe restlessness.’

"The statement also identifies signs of mania in children, including a decreased need for sleep, exaggerated or inappropriate silliness, exaggerated optimism, behaving as if invincible, atypically high energy levels, exaggerated talkativeness, racing thoughts, extreme restlessness or impulsivity, and inappropriate sexual behavior.

"The committee stressed the need for extra attention when medication is first prescribed or when it is changed. In some children these events have been linked to an increased risk for suicidal behaviors, so they caution against abrupt discontinuation of medication, which can exacerbate the illness and its symptoms."

Would it just be better to avoid antidepressants in kids?

No. There are definite benefits, especially with anxiety disorders, but also some depressions. The important thing is that patients, parents and clinicians be aware that these paradoxical reactions occur. They must monitor for negative reactions, which usually occur in the first few days or weeks. Kids that have done well on these meds for several months are at very low risk of an adverse reaction.

(1)"A recent analysis of suicide rates in the Journal of American Academy of Child and Adolescent Pyschiatry (2004:43) showed no significant difference between SSRI’s and placebo."

But they recommend additional studies to separate the effects of the illness, the medication and the interaction of the two. Of course, in formal studies patients are more closely monitored than in most office practices.

A recent study of communities looking at number of kids/teens taking antidepressants and rate of suicide in them found that the highest suicide rates occur in the communities using the least antidepressants. So in general, the benefit outweighs the risk. But in any given individual a complete history, including family history, good patient/family education, and close monitoring are essential for good medical care.

Footnotes: (1) CNS News, October 2004

I am a bibliophile, a person who loves books. My friends and family would probably say I am more a hoarder of books, journals, magazines and notes. (More about what causes hoarding later.) I love going to book stores and I always see what they have on medicine and neuroscience. I don’t think it’s a coincidence that there are more books on thyroid than any other subject. I believe the reason is low thyroid is an extremely common, fixable problem that may be more frequently mismanaged than any other medical condition. Proper treatment improves fitness and quality of life but most doctors don’t get it.

There are two maladies that I have noted in some physicians, PRE EXTRACTION DISORDER and MILK OF MAGNESIA DEFICIENCY. In the first condition they lack important information or don’t understand key principles because their head is somewhere in their sigmoid colon. In milk of magnesia deficiency, they believe things that are sometimes creative or at one time believed, but unfortunately not true – ergo they are full of crap. You may think this point of view is unkind, and you’re right. I believe that as an ADHD person I was put on earth to stir things up and challenge the system, so I won’t apologize for being at times "tacky".

Why are there so many books about thyroid? I believe when a doctor "gets it" and starts treating low thyroid effectively, they realize how often it is mistreated and how many patients suffer the consequences. I could regale you with case after case of examples, but suffice it to say, I too feel compelled to try and educate the public and my physician peers about the physiology of thyroid hormones.

The thyroid gland in the neck secretes two primary hormones, the more abundant T4 and the more active T3. Most of our T3 is made in other parts of the body by converting T4 to T3. I am working on a thyroid article that will go into detail about all the important nuances, but the key points are:

• Thyroid regulates the activity of every cell in the body.
• Many people, for various reasons, are low in T4 and/or T3.
• Most doctors will order only part of the tests needed for accurate diagnosis (the TSH).
• Total T4 and T3 uptake and a multiple called T7 or free thyroid index (FTI).

The FTI is preferred by insurance companies because it’s cheap, not because it’s adequate. This test is unreliable according to many reputable texts, so I consider it to be useless. The most important test is the Free T4 and sometimes the Free T3. Even when the Free T4 is within normal range, it may be too low for the individual. It would be analogous to giving you an IQ test in which you scored 90, and I told you this range was normal. The normal average range of IQ is 90-110, but what if you said "my IQ used to be 130"? … Something’s wrong. That may be the case with your thyroid.

One reason that this is missed is that most doctors don’t ask about thyroid symptoms (or a lot of other symptoms for that matter). But if you have fatigue or easy fatigueability you need to review all the possible symptoms: Dry skin, hair loss, sensitivity to cold, constipation, swelling, decreased memory, depression, or mood sensitivity, weight gain, difficulty losing weight, and infertility.

Even when low thyroid is treated, it usually is undertreated. The main medication used is Synthroid (the generic is especially unreliable). Many patients also need T3, either Cytomel, or in combination Armour or Thyrolar.

In the past 2 years I have attended two lectures by different Endocrinologists who talked about treating low thyroid. They talked about TSH, estimated Free T4 and treatment with Synthroid. No discussion of secondary hypothyroidism (low thyroid) which means due to causes other than an underfunctioning of the thyroid gland. Neither presenter talked about the role of T3 or use of T3 in treatment.

The books on medicine and endocrinology all say that for secondary hypothyroidism the TSH is useless, and yet, that is frequently the only test they get. At the second talk I asked if they believed that the soul was in the pituitary. This is the gland that helps regulate thyroid by monitoring levels and secreting TSH. But the problem is the pituitary (the master gland just outside the brain) is regulated by the hypothalamus in the brain.

Years ago a study found that if post menopausal women not on estrogen were treated with too much thyroid it could worsen osteoporosis. Ever since there is a fear of causing bone loss, and the result has been a lot of undertreatment. The problem is over reliance on the TSH and fear of osteoporosis, "osteophobia."

In secondary hypothyroidism the thermostat for body temperature and the set point for basal metabolic rate is set too low. I believe a common cause is "hibernation."  Many of us are mostly indoors and some are mostly sedentary. But we adapted over 1000′s of years to being outside all day and physically active. Our energy and sleep were regulated by the bright outside light. Even on a cloudy day it is 10x’s brighter outside than inside. If our brain thinks we are hibernating, and especially if we have cultural heritage from the northern countries, then we compensate by reducing our metabolism until the weather permits productive outside activity. By reducing our temperature and metabolism we conserve energy (stored as fat). This is also why it’s very difficult to lose weight.

If our hypothalamus is set too low the pituitary will read our level as too high when we take an adequate healthy amount of thyroid medicine. The TSH will then be below the normal range – this is fine. But most doctors overreact and lower the thyroid medicine. Now the patient feels terrible, but their TSH comes up and the doctor is happy – pre-extraction disorder. Most doctors are conscientious. They want to do what’s best for their patients, but in the case of thyroid, they mostly don’t get it.

Low thyroid can cause or worsen depression. In women it is:

Thyroid x Estrogen x Brain transmitters (norepinephrine, serotonin, dopamine) = MOOD

It’s like for your car you have to have gas, oil, and water. You can’t compensate for no gas with more water. You can’t compensate for low thyroid with an SSRI (antidepressant such as Lexapro). In men testosterone is more important than estrogen. The brain converts testosterone to estrogen in men and women. Older men have more brain estrogen than older women (who are not taking estrogen). Older men have half as much Alzheimers – the only common cause of premature death more common in women.

In bipolar disorder Synthroid or T4 needs to be in the upper part of normal range to help stabilize mood. T3 is more of an antidepressant but obsession by "osteophobic" physicians results in inadequate treatment doses to help with mood. "The operation was a success (we kept the TSH up) but the patient died."

I will cover osteoporosis in detail later but just a note – adequate estrogen/testosterone/DHEA, weight bearing exercise, and adequate calcium is the prevention/treatment.

Other than that I have no opinions.

Read Part 1
A very successful friend of mine recently said – "I need to come see you. I’m depressed half the time, and I’m having panic attacks." Other than the pressure of a successful business, he has no reason to be depressed. He’s tried a variety of treatments before and still occasionally takes medication.

In all likelihood, he has a form of mood disorder called bipolar. In practical terms it means common treatments like antidepressants or stimulants for ADHD given without first being on a "mood stabilizer" would cause more problems than they would solve.

According to Dr. Fred Goodwin (arguably the leading authority on bipolar disorder in the world), Dr. Emil Kraeplin more than a hundred years ago had a better understanding of bipolar disorder than the criteria in DSM IV. Dr. Goodwin believes that highly recurrent episodes of depression – especially disproportionate to life stressors – is closer genetically to bipolar disorder and responds better to mood stabilizers than to antidepressants.

Mood stabilizers are medications that help both depression and symptoms of mania (euphoric grandiosity or agitation/irritability), or at least mood stabilizers help depression or mania without making the other worse. The name bipolar refers to the two extremes, up and down; but the cyclicity component is equally or more important. Hence, Goodwin believes the old term manic depression illness is more accurate and useful.

What does this mean for my friend? His life would probably be a lot better on a mood stabilizer, but given his history, he’s unlikely to take action any time soon. When he’s feeling good – he’s hopeful that down days are over, so he doesn’t really need help. On the other hand, when he’s down, he barely has the drive and capacity to get through the essentials of the day – he doesn’t have the energy to call and make an appointment and then to go in for an evaluation. It’s "Catch 22" all over again.

Some sad facts about bipolar disorder: 

National Depressive and Manic Depressive Association (500 & 600 people) in 1990 and again in 2000 show that the medical establishment is making very, very slow progress.

     Bipolar patients misdiagnosed as unipolar depression:

     1990 – 73%

     2000 – 69%

     Bipolar patients whose diagnosis was delayed by 10 years or more:

     1990 – 41%

     2000 – 39%

Why are we doing such a poor job? The system is broken. We need a complete shift in paradigm. Patients and doctors need to take the controls back from insurance companies.

The last 52 years in psychiatry reflect the lack of solid scientific foundation. We need official diagnoses so we can use our insurance for medications. But diagnoses are not the "be all, end all." I tell patients I’d rather not know exactly what the problem is and be able to fix it, than understand it perfectly and be unable to do anything about it.

If you’re struggling more than you think you should be, or more than a lot of people you know – there may be help available to make things easier or enhance your quality of life. You need to find a physician or counselor who treats patients, not just symptoms or diagnoses. Two cases in point – ADHD and bipolar disorder.

A great example is the diagnosis of ADHD – one of the most important disorders in medicine because of the negative consequences to productivity and relationships and the relative ease of highly effective treatment. Ironically, in a recent survey, 15% of primary care physicians felt comfortable diagnosing and treating ADHD – in contrast to 85% anxiety and 95% depression. This lack of comfort and confidence in treating ADHD is undoubtedly related to the higher regulatory controls and requirement for written prescriptions in many states – even though pain meds (esp. hyrdrocodone) and tranquilizers (esp. butalbital, diazepam & alprazolam) are much more likely to be abused according to a recent government-funded study.

I remind patients in the office and doctors when I’m teaching that our diagnostic manual (DSM) was not given to Moses on the mount. We change it every few years. It was published in the 1930′s that hyperactivity and behavioral problems improve through use of stimulants, but the first version DSM I (1952) made no mention of the disorder.

In DSM II (1968) the diagnosis was hyperkinetic disorder of childhood, and concentration problems were thought to be due to hyperactivity. I’m frequently reminded of Yogi Berra’s comment "I wouldn’t have seen it if I hadn’t believed it." Because in 1980 (DSM III), the diagnosis was changed to attention deficit disorder with two subtypes – inattentive and hyperactive. Symptoms of impulsivity were required for both types.

In 1987 DSM IIIR, they flip flopped on panic disorder and said that agoraphobia was caused by panic attacks instead of vice versa in 1980. The diagnosis of ADHD was changed again. They eliminated subtypes and included inattention, hyperactivity, and impulsivity symptoms. You had to have at least 8 of 14, and since there were less than 8 inattentive symptoms, this subtype fell off the radar screen.

Then in 1994 a factor analysis showed there were 2 symptom clusters – inattentive symptoms and hyperactivity/impulsivity symptoms. This is reflected in our current manual DSM IV published that year. So now you can be diagnosed either inattentive, hyperactive/impulsive, or both. Each subtype requires 6 different symptoms before age 7 with significant negative consequences in at least 2 settings.

There are several reasons these criteria are problematic, the main one being that the highest levels of brain function are not fully developed until the very front of the brain is matured – but this doesn’t occur until the early 20′s. Furthermore, scattergram analysis reveals the higher the IQ, the more likely the diagnosis will not be made until early adulthood or even midlife. Fortunately the current manual includes a category ADHD NOS (not otherwise specified) for people with enough symptoms to cause problems in at least one area of their life but not enough to get a full blown diagnosis.

In a few years we’ll have DSM V and all new rules – meanwhile, we’ll make due with what we have.

Read Part 2