Sunday, May 31, 2015

The Truthfully Maddening Dilemna of John Nash's Story

John Forbes Nash Jr. was a brilliant mathematician and a suffer of something, depending on whom you ask, in the neighborhood of schizophrenia and manic depression.

Nash, who died in a car accident with his wife a little more than a week ago, was, first and foremost, a Nobel laureate, whom, like many mathematicians, made his greatest discoveries in his 20s (As G.H. Hardy wrote in 1940, of “all the arts and sciences mathematics is the most remote” and “no mathematician should ever allow himself to forget that mathematics, more than an other art or science, is a young man’s game”).

Knowing that history and those peculiarities of mathematics and mathematicians, strange behaviors –extended solitude, writing equations on walls, a frenetic pace to develop solutions, mumbling to themselves in public – probably did not seem so far outside the norm among his brethren at Princeton University.

But, according to a 2010 edition of The Princetonian, the daily newspaper at Princeton, Nash was an eccentric among eccentrics. The newspaper said that Nash, as a student, became known as “The Phantom of Fine Hall,” a shadowy figure who would scribble arcane equations on blackboards in the mathematics building middle of the night and the walls of toilet stalls during the day (it says something mathematicians at Princeton that this was not considered a prime facie case for mental illness).

Nash’s mental illness, as it was identified at least, first began to manifest itself as erratic behavior and then paranoia. First, there was the communist conspiracy against him. He mailed letters to embassies in Washington, D.C. declaring that the communists were declaring a government. Then, there were the aliens. And, finally, his psychological battles broke into his professional life at an incomprehensible lecture he gave at Columbia University in 1959.

That year, Nash was admitted into McLean Hospital in Belmont, Massachusetts and was diagnosed with paranoid schizophrenia (although, his biographer, Sylvia Nassar, writes that his likely actual diagnosis may actually be bipolar disorder, or manic depression, with psychotic features). There, doctors discovered, that Nash was not just suffering from paranoia, but also auditory and visual hallucinations – essentially perceptions of things that were not actually there. In 1961, he was hospitalized again in a state hospital in Trenton, New Jersey.
His colleagues were baffled.
In Nassar’s book, she writes:

            John Forbes Nash Jr. – mathematical genius, inventor of a theory of rational behavior, visionary of the thinking machine – had been sitting with his visitor, also a mathematician, for nearly half an hour. It was late on a weekday afternoon in the spring of 1959, and though it was only May, uncomfortably warm. Nash was slumped in an armchair in one corner of the hospital longue, carelessly dressed in a nylon shirt, that hung limply over his unbelted trousers. His powerful frame was as a rag doll’s, his finely molded features expressionless. He had been staring dully at a spot immediately in front of the left foot of Harvard professor George Mackey, hardly moving except to brush his long, dark hair away from his forehead in a fitful, repetitive motion. His visitor sat upright, oppressed by the silence, acutely conscious that the doors to the room were locked. Mackey finally could contain himself no longer. His voice was slightly querulous, but he strained to be gentle. “How could you,” began Mackey, “how could you, a mathematician, a man of science, a man devoted to reason and logical proof … how could you believe that extraterrestrials are sending you messages? How could you believe that you are being recruited by aliens from outer space to save the world. How could you …?”
            Nash looked up at last and fixed Mackey with an unblinking stare as cool and dispassionate as that of any bird or snake. “Because,” Nash said slowly in his soft, reasonable southern drawl, as if talking to himself, “the ideas I had about supernatural beings came to me the same way that my mathematical ideas did. So I took them seriously.”

Nash was placed on medications and never hospitalized again. Or so goes the premise of the 2001 movie that was made about him, starring Russell Crowe, called “A Beautiful Mind.” Those of us who suffer from mental illness and accept treatment want to believe that we can have the brilliance, the beauty without the madness. There is no empirical evidence to suggest that preserving brilliance while in treatment is impossible. But Nash's story certainty does not make the case.

The popular convection of Nash’s story is about the connection between brilliance and madness, and it gives hope to those whose creativity and intelligence appear linked to their mental illness. It screams that you have both sanity and brilliance. I believe that it is possible – but it’s hard to not look at Nash’s story, and those of many others in similar positions, and think that you might just have to give up a little of one of those things for the other.

The truth is Nash never really took to medications, and said that he would only take them under extreme pressure.  In 1978, Nash won the John von Neumann Theory Prize for what is now called the Nash Equilberian (in 1994, he won the Nobel for game theorem work he developed while a student at Princeton). But Nash likely never found an equilibrium between brilliance and madness in his own life.

I remember watching the movie for the second time with a friend who had been diagnosed with manic depression. This creative friend had struggle with her diagnosis. By the middle of the movie, where the viewer begins to realize before the character of Nash in the movie that he is not truly being hounded as a part of a vast government conspiracy, she began to cry.

When we discussed those tears, it was sadness both for the character on the screen and for how the movie broke the dichotomy that we so easily construct with brilliance in one place and madness far away on the other side. It is easy to listen to the stories of Winston Churchill, Sylvia Path, Van Gogh and Mozart, and believe that, now, with medications there is hope to find a way to intermindle, to tam the madness that so often comes with brilliance without snuffing out that spark.  

What makes Nash's life so painful for me is that it does not provide any clear answers about the interconnections between brilliance and madness or whether, as some have argued, that people like him can have one without the other. It does not make the case I want it to make -- that you can be in treatment and still be brilliant.

Hearing Nash speak several years ago at the University of Maryland at College Park struck me in a number of ways -- one of them particularly relevant to this discussion. Nash was discussing game theory. And, I and those around me, including leading mathematicians of the day, did not understand a word he said. In our group that day, we all thought that it was simply because his mind operated on a different plane than ours -- that we just were not smart enough to understand it. 

Now that I better understand his life, I wonder whether it wasn't just that he was so brilliant that we did not understand him. Perhaps he was just so mad that we could not understand him.

Sunday, August 24, 2014

The Many Faces of Robin Williams

Standing in the front of the coffee table last night, I picked up my phone to check the news and saw the headline. Robin Williams was dead at the age 63. I clicked on the link with a mindset that some horrible accident must have happened. Perhaps he died of a tragic illness that took his life early, like cancer. I was right about the tragic illness, it appeared. I had just picked the wrong horrible disease.

Early reports suggest that Williams, the actor and comedian known for his standup and movies like “Good Will Hunting,” “Patch Adams” and “Mrs. Doubtfire” died of asphyxiation, most likely caused, according to the Marion County, California sheriff’s office, by suicide. That Williams suffered from drug addiction I knew from his standup. What I did not know was that he suffered from the same disease that ailed me, bipolar disorder.

In a 2006 episode of “Fresh Air,” the NPR radio show, Williams told host Terry Gross, “Do I perform sometimes in a manic style? Yes. Am I manic all the time? No. Do I get sad? Oh yeah. Does it hit me hard? Oh yeah.”

According to news accounts overnight, Williams’ spokeswoman, Mara Buxbaum, said that he had “been battling severe depression as of late.”

I sent a text to several friends who could relate, either because of their mental illness or their addictions. To one message with a friend who also has bipolar disorder, I wrote back, “Shame. For us at least. Hard to say whether it was for him.”

My comment may have seemed callous, but my friend knew what I meant. He wrote back, simply, “I agree.” The truth is that while it may be hard to understand why another person takes their own life, if you’ve been on the brink of that choice, you understand, as Kay Redfield Jamison, a professor of psychiatry who also has bipolar disorder, put it in the title of her book on suicide that ‘night falls fast.’

There is no question, as one commenter put it, that suicide is an insidious choice due to the lies that depression tells us. When those thoughts persistently and pervasively bombard you day in and day out or when they come out of nowhere like a drone attacking in the night’s sky, they can tear you down to the shreds of yourself, wither your resolve and leave you gasping for breath. The only way you see to stop the suffering is to end your life. People say that’s when suicide happens - when people listen to those voices, but I find that to be a metaphor that leads to gross over-simplification – you have little choice about whether you can listen to those voices. It’s your actions that hang in the balance.

By all accounts, Williams made every effort to seek help. By his own account, he spent 17 years clean and sober between 1986 and 2003. He described an addiction to cocaine and was a frequent partner, he said, alongside John Belushi, who died in 1982. Williams said on the show “Inside the Actor’s Studio” that the death of his friend and the birth of his son. “Was it a wake up-call?” Williams asked. “Oh yeah, on a huge level. The grand jury helped too.”

Bipolar disorder, I find, is such a benign phrase for such a terrible disease. It certainly has much less stigma attached to it than its preceding name, manic depression. But manic depression more aptly captures a disease that slams you from what can be a painful high to a crushing low, sending you up again often into a vice where both mania and depression, not mutually exclusive conditions, can squeeze you at the same time in a powerful vice. Too often, in an effort to show people how well those with bipolar disorder can function in life, we minimize how damning the disease can be for the sufferer.

Williams said that he relapsed via alcohol in 2003 while working in a small town in Alaska. In 2006, he checked himself into a substance abuse rehabilitation in Oregon. Williams’ addiction garnered much attention, but his struggle with the underlying conditions, as is true for so many people who get sober, did not. Williams’ co-stars on the set of “The Crazy Ones” said that he appeared so healthy this spring. It is a testament to how deceptive these diseases of the mind can be to the outside observer.

“He seemed to have this aura about him,” the actress, Marilu Henner, told USA Today. “But you don’t really know what lies beneath. It makes me so sad that it came to this.”

But like Williams, we all have many faces. His, at times, masked another solider in a silent army, fighting a secret war that their friends, family and admirers might not always see. Instead of focusing the very real sadness of his suicide, I want to raise a glass to Robin Williams – of something non-alcoholic, as a recovering addict myself – and hold a parade in his honor, for fighting this terrible disease for so long. He may not have made it through the battle, but his effort can be an inspiration for the rest of us to fight.

Saturday, September 28, 2013

My Rubix Cube and McLean (Hospital)

I love being home on Saturdays with my family. I enjoy my morning rituals. I enjoy the hikes we tend to take along the Potomac River, the museums we visit and the dinners in Washington. I especially like my morning espresso at the coffee shop down the street from where I live and the espresso at a Georgetown place better known for its cupcakes. I like my rituals.

So, its with hesitation that I interrupt them. Doing so has a tendency to scramble the Rubix cube in my brain. Like any Rubix cube, it can be difficult to get back in order again.

As I headed off to the Harvard Medical School-McLean Hospital conference on Coaching in Leadership and Healthcare this weekend, I thought that my Rubix cube had a chance of being broken if it turned out to be a disappointment. Well, its still in tack and I am walking away from the conference with a few more techniques on how to solve my own puzzles and help others put theirs together.
My concern came from the simple fact that some many of the people that I have encountered in professional coaching, both as someone who hires coaches and who works with them, lack the tools to really help my clients where they are. Many coaches do not want to work with people who have certain problems. I’ve met wellness coaches who don’t want to work with people who have serious mental health or addiction problems (I’m waiting to meet the food addict client who isn’t an addict). I have met life coaches who are really cool with working with anyone as long as they don’t have an anxiety disorder, a mood disorder, a personality disorder or any of those other things that would make them prime beneficiaries of coaching. They're there to help, but only if your problems are easy.

There is no question, in many situations where people have serious mental health problems, the client should have a psychiatrist and/or a therapist involved in their treatment. But I firmly believe that there is a role for a good coach to help turn ideas into action, reduce failures and keep crises from turning into derailments. With the backdrop that not everyone in the profession agrees with me on this approach, I came to the conference fearing that it would be dominated by that type of thinking.

I was pleasantly surprised. But, really, I shouldn’t have been. McLean Hospital is the renowned hospital of “Girl, Interrupted” fame that is known for its respected milieu treatment programs and its ground-breaking neuroscience research. Famous former patients include singer-songwriter James Taylor, Nobel-prize winning mathematician John Nash, poet Sylvia Plath and authors and Susanna Kaysen, according to Gracefully Insane: Life and Death Inside America’s Premier Mental Hospital. David Foster Wallace was treated there, according to a recent biography, and so was Frederick Law Olmsted, who both selected the plot of land for the hospital and was a patient. Part of Plath’s memoir, The Bell Jar, includes time spent within the campus walls. I've referred clients to McLean for the treatment of dissociative disorders and borderline personality disorder, two areas where the hospital is considered ahead of the curve.

Most of the debates about coaching as a profession center on licensing as a means to regulate the practice and membership. It’s a debate that frustrates me because I fear that it could lead to an entire population of people who need coaching the most -- those with mental health problems -- to be excluded from receiving services. I also worry that the peer specialists, like the recovery coaches hired by the Fairfax-Falls Church Community Service Board and the public Loudoun County Mental Health, would be left in the dust in a liscened paradam. In essence, I fear the namby pambies will win, and coaching will turn into a profession of yoga, meditation and singing kumbaya for only the people who don’t have a condition in the Diagnostic and Statistical Manual of Mental Disorders.

It shouldn’t come as a surprise that the No. 1 psychiatric hospital in the country, which is among the top 15 recipients of National Institutes of Health grants, would confront mental illness head on and their work would be heavy on the science. Research was presented on the impact of emotional intelligence on leaderships effectiveness, coaching and healing, cross cultural coaching, coaching to create creative learning, coaching for physician leaders and a variety of technique and population specific research. Techniques like motivational interviewing, solution-focused coaching, narrative coaching, cognitive behavioral coaching and psychodynamic coaching were explored in depth. Empirical evidenced based research was littered throughout all the presentations. Discussions about utilizing techniques from mindfulness, dialectical behavioral therapy and other modalities were common. fMRI scans seemed to be in every other presentation.

Pamela Peeke, MD, a physician-coach who is a professor at the University of Maryland School of Medicine, presented on the addicted brain. She discussed the similarities between food addiction and drug addiction, discussing how consistent consumption of either can lead the brain to reduce the number of dopamine receptors to protect the mind. This, in turn, means it takes more to get the same feeling in the rewards center of the brain. That’s how one cupcake a day becomes 13, she said, adding that the research has helped coaches, therapists and psychiatrists to help clients focus on mindfulness, hypervigilance and executive function problems in order to buy time for those receptors to grow back.

Using data from research from Nora Volkow, MD, the director of the National Institute on Drug Abuse (and Leon Trotsky’s great granddaughter)  and her team, Peele laid out strong research showing the reasons why willpower -- the fact that addiction impacts the regulating executive function part of the brain and the rewards center part of the brain -- is such a failure in addressing any type of addiction.  

Robert Kegan, PhD., the Havard professor, discussed immunity to change, noting that the “immune system is a beautiful system, designed to protect us, but sometimes it can get us into trouble when it treats something as a threat that is not.” He compared people’s difficulty with good change to an “autoimmune reaction.” Kegan noted that the amygdala -- the fear center of the brain -- “gets a bad wrap” because its needed to keep us safe, but that when it goes wrong “it’s like having one foot on the gas and one foot on the break.” Kegan laid out strategies in a case study about how to help people with change.

Michael Pantalon, PhD, a Yale University assistant professor of psychiatry and director of the Center for Progressive Recovery, discussed how giving clients autonomy -- acknowledging that they have a choice and empowering them to make one -- has helped increase attendance among parolees for meetings with their probation officers and improved outcomes in drug treatment. 

Three physicans in the session highlighted the application of this approach in medicine and mental health. 

In the session, a cardiologist noted that physicians are trained to be dietetic -- to tell patients what to do -- and noted that she was beginning to finally see why that was not working. A family physician who is a coach highlighted how this coaching model had changed outcomes for his patients. After becoming a coach, he stopped telling clients what to do, and started casually hanging ideas out there. In one example, instead of telling a client who was trying to lose weight what to do, he mentioned that he had lost 130 pounds. The client asked about the diet and adopted all of it except the part about not eating pasta. Instead of telling the client to not eat pasta, he said ok and the client asked what would change. He replied, "You won't lose weight." The client ultimately decided to give it up. In addition, the director of a large psychiatric hospital described a patient who had long been on their inpatient unit who had become so entrenched that she would grab something to hurt herself whenever she was walking in the hallways. He said the staff all wear mitts to try to slow her down. The hospital director mentioned that they had told the patient she should use the tools she's learned on the unit. Pantalon coached the director on how to essentially say, "You can use the skills you've learned if you want to. You can also continue to hurt yourself. It's your choice." I guess we'll see how it works next year. But if Panaton's own examples from working with addiction clients are any indication, my betting money is that empowering the patient will be successful.

A session by Ronald Schouten, MD, an associate professor of psychiatry at Harvard and the director of the law and psychiatry service at Massachusetts General, was cancelled at the last minute. It’s a shame. He was going to talk about what coaches should do when they come across those who are and who are almost psychopaths, alcoholics and depressed in their practice. Perhaps, this time, next year. I’ll be back. The other speakers included David Peterson, the director of Leadership and Coaching at Google, and Richard Ryan, PhD., a University of Rochester professor who spoke on self-determination, specifically the importance of intrinsic motivation in volitional behavior.

But the most powerful part of the conference was listening to my colleagues themselves. The issues that they are working on, struggling with, researching and tackling are impressive. The skills that they brought to the table -- like the executive coaches who were as skilled in psychology and organizational development as they were in finance, and the life coaches who knew when to bring to bear insight-oriented, cognitive behavioral, dialectical behavioral and action-oriented approaches stood out.

What was most heartwarming, were the side table conversations about clients. The coaches I met showed a passion for making their lives of their clients better with a matching desire to take the most intelligent, evidence-based approaches.

I came out of the conference with dozens of new tools to help my clients, and a lot more hope for the profession. I feel like my Rubix cube isn’t just unbroken. I feel like I got another one. And that means many more tools for my clients.

Tuesday, July 31, 2012

Jonah Lehrer

I wrote a piece for Newsweek last night and gave a Q&A to Salon on the journalism scandal involving Jonah Lehrer. I have sympathy for him. Another young promising journalist whose self-sabotage is lead to the end of his career (he worked for The New Yorker until yesterday). I vividly remember that feeling of not being able to let go as my career crumbled like the Monte Cassino under weeks of Allied bombing in World War II Italy. Its hard to let go even when the building is crumbling. I know its probably feels like the end of something special, but I hope this bright young man finds redemption waiting for him in the future.

Friday, July 27, 2012

Shalom to a Friend

Shalom is a word that has many meanings. It is a Hebrew word that
means peace, welfare, completeness, hello and goodbye.

In his 1995 eulogy at Yitzak Rabin's funeral, Bill Clinton captured the
world when he uttered the simple Hebrew phrase, "Shalom Chaver" --
Farewell, my friend.  This week I had the unfortunate duty of saying
goodbye to my friend.

In Beth Nielsen Chapman's song "Sand and Water," which is about the
premature death of her husband, she sings "All alone, I came into this
world. All alone, I will someday die." And so it was with my friend,
who died under a bridge, homeless and alone.

There is, however, a notion embedded in that song about the impact a
person can have in between those two points of being alone -- the
impact they can have on our lives. As Nielsen Chapman sings, "I will
see you in the light of a thousand suns. I will hear you in the sound
of the waves. I will know you when I come, as we all will come.
Through the doors beyond the grave." My friend would have appreciated
the metaphor -- he loved the beach and he died on the water near one.
He would appreciate that his life continues on through his kind words,
good ideas and other things that he has done.

People have said that I should feel no guilt at this passing. I
understand that I should not be ashamed. I understand that I did, in
each moment, what I thought was best. But I also believe what Judith
Viorst wrote in her book Necessary Losses, that losses "... are a part
of life-universal, unavailable, inexorable. And these losses are
necessary because we grow by losing and leaving and letting go." And
part of what I can learn to honor my friend's death are new tools to
help others in the future. And I will do this, in his honor. I can
also help others learn by sharing his story.

I wrote a note to a group of friends who had something in common with
my friend. We all suffer from either bipolar or depression. It was
meant to be a personal way to let them know of his passing and his
impact. I made the decision to share it here after getting a note from
one of those within that group who said that she hoped his story
reached a larger audience and also said, in part, that:

"In your piece, you've helped me appreciate what a fighter he was.
You've also done a masterful job of unmasking his unrelenting foe,
manic depression. Where's the parade for a solider who dies in a war
like that?"

This is that parade:

    Clark, our friend and one of the earliest members of the
    Centreville DBSA meeting, was found dead under a bridge in Virginia
    Beach. His family learned the news of his death yesterday. He
    was 46.

    The cause of death was pulmonary embolisms caused by deep vein
    thrombosis that was caused by, according to police, "dehydration,
    malnutrition and the homeless lifestyle."

    I knew Clark as an intelligent, good and loyal friend with a rich
    sense of humor, who had a great amount of compassion. He loved life
    and the people around him. We say this after almost everyone dies, but
    he was, truly, a good person. Clark was an enthusiastic member of the
    group, as interested in helping others facing bipolar and depression
    as he was in getting help himself. He helped us start our third group
    in Ashburn.

    Clark was open about his lifelong struggle with bipolar disorder. Before
    suffering from his first full-blown manic episode, Clark, who grew up
    in Montgomery County, received a Bachelor of Arts degree in government
    and politics from the University of Maryland, worked as a computer
    specialist at the U.S. Department of Health and Human Services, a
    regional manager for Hallmark Corporation, a data control specialist
    for Miami-Dade County and founded an online auction company.

    Clark's first major manic episode was devastating and sent his life
    spiraling out of control for several years. Clark was not be able to
    rebuild his life until he was jailed and then hospitalized as a result
    of that manic episode. Clark did a miraculous job during his early
    recovery, settling in Northern Virginia and getting back on his feet
    by working for Excel Courier in Sterling. After joining the
    Centreville group in early 2006, Clark obtained a position, through
    help from another group member, as a customer service administrator at
    Procraft in Chantilly. Clark left that position in 2007 to return to
    Virginia Beach after his mother's passing.

    At the time, Clark felt his recovery was going strong, as he had found
    a good psychiatrist who continued to provide him transitional care. He
    joined a church there, attended DBSA-Virginia Beach meetings and
    helped with his mother's affairs. Along the way, Clark worked in
    several jobs and had gone several years without a manic episode.

    In early 2010, Clark sought out a new psychiatrist, whom he said told
    him that he had ADHD and not bipolar. He later told me that he wanted
    to believe the doctor, even though he knew this was not the case.
    Clark's family and friends tried to intervene, with his brother going
    as far as reaching out to the doctor to explain the symptoms that
    Clark had experienced over his life. But the doctor put Clark on
    Adderall and took him off Lamictal, which sparked a manic episode that
    sent his life spiraling downward.

    Late last year, Clark told me he would do anything to get medication.
    But the Community Service Board in Virginia Beach told him he would
    have to wait. He no longer had insurance and was coming to grips with
    the devastation wrought by the episode. He was homeless, estranged
    from many family members and friends, sleeping in cars until he did
    not have one, and on streets after then. He was depressed and anxious,
    barely able, he said, to get two hours of sleep each night.

    In December of last year, Clark disappeared. As the months passed,
    many of us who were his family members and friends reached out in
    desperate attempts to find him. Many of us feared the worst as we
    hoped for the best. In May, Clark finally reached out to a family
    member, who was unable to connect with him because they were not able
    to return his call from a pay phone.

    It is unclear what Clark's final days and weeks were like, but I can
    imagine from what the final year of his life was like -- homeless,
    sleeping on streets, begging for food and friends, searching for a way
    to get on his feet and praying to the God he believed would help him
    find answers. One recent day, a group of recreational boaters saw Clark
    sitting under a bridge. When they returned a few minutes later,
    they saw him lying on his side. They called the police, but Clark had
    already passed by the time the police arrived.

    I know what Clark would want me to say to you right now. To those of
    you who were his friends, he would say, as he had said so many times,
    that he loved you and he'd thank you for all that you have done for him. To
    those who didn't know him, he would tell you, as he said in December,
    that his life was a cautionary tale, a story of the struggle that
    those of us with bipolar face with a disease that convinces us that we are
    not ill.

    I miss him so much already. But, with these words, I hope to honor his

Shalom, my friend, in every meaning of the word.

Wednesday, January 4, 2012

The Importance of the Accuracy of Diagnosis

By Jayson Blair, Certified Life Coach

The importance of a good diagnosis has become even clearer as pharmaceutical companies have further refined their biological silver bullets for mental illness. Medicines like, for example, serotonin reuptake inhibitors can be targeted to treat depression, obsessive compulsive disorder and a variety of other illness. But they can have dramatically harmful effects on those with bipolar disorder. All things considered, its amazing that doctors are not more attentive to the symptoms faced by their clients. But increasing demands of the economy and insurance companies have made it harder, to potentially devastating consequences, for psychiatrists and psychologists to effectively diagnosis.

Increasingly it is fallen on clients to rapidly self-report symptoms in 15-minute to 30-minute initial evaluations and then the question of diagnosis never return. In the best practices of the profession, diagnosis is thoroughly evaluated and constantly re-evaluated. Clients, for better are worse, have become their now diagnosticians.

Gregory House, the fictional doctor on the show House MD, is in some ways a joke about the trend that doctors rarely have time for accurate diagnosis (his fictional Department of Diagnostic Medicine makes no money and runs up huge bills for the hospital). This article is designed to help clients identify and self-report their symptoms.

This article examines differential diagnosis of bipolar disorder and other illnesses. Subsequent articles will look at ADHD, anxiety disorders and personality disorders.

Bipolar Disorder and Depression

Bipolar disorder and depression are often the toughest differential diagnosis for the most seasoned mental health professional. Clients most often come in from the rain of depression to seek treatment and rarely seek a helping hand when they are manic or hypomanic. This means that those with bipolar, whose illness includes the symptoms of depression and mania, are often misdiagnosed with major depression.

This would hardly be a big deal if the front-line treatments for depression didn’t cause mania (often rapid cycling), which often includes high risk, life-changing behaviors that can be harmful and mentally painful to clients and their families.

Epidemiologists say that bipolar disorder effects 1% to 2% of the population and that about 10% of those with major depression will later develop mania. The first occurrence is often in childhood, teenage years or early adulthood. There is no gender difference when it comes to the prevalence of the illness.

The symptoms of mania, which can used to differentiate from depression, vary from person to person. They can include eutrophia, irritability, agitation, inflated self-esteem, poor judgment, rapid and pressured speech, aggressive behavior, increased goal-directed activity, risky behaviors, spending degrees, delusions an increased drive to perform and frequent work and social problems. A helpful Mayo Clinic article on mania can be found here.

ADHD and Bipolar

Steriods and stimulants can have the same effects, so it’s very careful for bipolar to be differentiated from bipolar and attention deficit hyperactivity disorder. Atypical antipsychotics that can be used to calm manic storms can exasperate inattention. A preteen or a teenager with mood swings may be going through a difficult but normal development stage. They could be suffering from actual bipolar disorder with periodic mood changes going from depression and mania.

In addition, symptoms of ADHD often mimic symptoms of bipolar disorder. With ADHD, an individual may have rapid or impulsive speech, physical restlessness, trouble focusing, irritability and, sometimes, defiant or oppositional behavior. There are some similarities.

While ADHD is characterized by inattention and most often some distractibility and hyperactivity, bipolar disorder is characterized by mood swings between high energy and activity and feelings of sadness. People with ADHD may feel sad or even depressed, but rarely with the persistence and cycling of bipolar. Another sign is that hyperactivity and inattention symptoms persist in people with ADHD while they don’t always in bipolar.

Borderline and Bipolar Disorder

Borderline personality disorder is a persistent and pervasive illness that causes emotional instability, leading to stress and other problems, including temper tantrums, self-mutalization, elevation and devaluation of people, fast and furious relationships that crash and burn, frequent feelings of inadequacy and fears of abandonment.

From a medical perspective, differentiating between bipolar and borderline personality disorders is not relevant for medical treatment. The two diseases are often treated with the same medications to stabilize a person’s mood. It is helpful because atypical antipsychotics can have added effect with bipolar disorder and anti-depressants can be more readily utilized with borderline personality. But the medical consequences of a misdiagnose are not enormously negative.

The differential is important, however, for therapeutic options. Bipolar disorder can be treated with a variety of psycho-therapeutic modalities, while borderline is most effectively treated with dialectic behavioral therapy and transference-focused therapies. These later treatments are some of my favorites; they focus on the relationship between the client and the therapist, helping clients understand emotions and the difficulties that develop in therapy. The relationship between the two often serve as a model for future relationships outside the safety of the therapeutic room.

Jayson Blair is a certified life coach with Goose Creek Consulting and can be reached here. This was first published on

DiffDx: Anxiety About Anxiety

By Jayson Blair, Certified Life Coach

It’s a jungle out there.

And one of the hardest forests to untangle your way through is the differences between stress and anxiety, and the differences between the many anxiety disorders. It’s enough to make you anxious. But no worries, we’ve put together a little guide.

Anxiety disorders have one of the longest differential diagnosis lists of all psychiatric disorders.

One of the biggest problems is that clients with anxiety disorders also have anxiety about their disorders, and anxiety about treatment, making self-reports and diagnosis a difficult thing to work your way through. No worries, though. It might take time, but a careful clinician can often differentiate for you, and help improve your quality of life.

The importance of these differences is a key to selecting the most effective therapeutic and medical treatments.

One of the most important issues is the difference between anxiety and plan old stress.

Stress vs. Anxiety

Wikipedia puts it this way: “Stress is a term that is commonly used today but has increasingly difficult to define.”

How true.

The Mayo Clinic puts it better than I ever could: “Its normal to feel anxious from time to time, especially if your life is stressful. However, severe, ongoing anxiety that interferes with day-today activities may be a sign of” anxiety disorders.

The key differences: severe, ongoing and inferring with living a healthy day to day life.

The same goes for fear. Gavin de Becker pines about the gift of fear in his excellent book by the same name. Fear and institution go hand and glove and as de Becker puts it, “Intuition is always right in at least two important ways: It is always in response to something. It always has your best interest at heart … Denial is a save now, pay later scheme.”

But when fear becomes irrational it can interfere with functioning and its safe bet you should be checked out for anxiety.

It’s true that many of the things that help with managing day-to-day stress – mindfulness, exercise, cognitive behavioral techniques, deep breathing, guided imagery and meditation – can be beneficial for some people who have anxiety disorders. But the reality is that therapy, coping skills and medications are key parts of addressing anxiety disorders that are not usually needed in managing stress.

Some good questions to ask yourself before you right off your anxiety as a not needing intervention are: do you feel tense and wound up for a significant amount of time? Do you feel numbness or tingling? Do you feel hot when stressed? Are you unable to relax? Do you feel a sense of dread? Dizziness? Is your heart racing? Do you have to do routines that interfere with your function or drive those around you batty? Do you feel losing control or death when the possibility does not seem realistic? Do you feel ridicule, rejection or abandonment when there is not real evidence that its coming? If you answer yes to an of those, I would suggest you see a therapist, a coach, a psychiatrist or your primary care physician and ask them to administer the Beck Anxiety Inventory (treatment providers should try to rule out the impacts of drug abuse, other mental health conditions, migraines, folic acid deficiency, seizures, caffeine-related disorders, CND-based sleep disorders, pregnancy and diabetes mellitus, among other potential disorders) .

The scores on the inventory not only guide clinicians on the question of whether you have anxiety but also what’s the best treatment. Being unable to relax suggests cognitive issues while feeling hot suggests autonomic symptoms. Feeling dizzy or lightheaded suggests nueromotor issues, while feeling like you are choking suggests a panic attack. These facts help clinicians design the most effective treatment for you.

Generalized Anxiety vs. OCD

Obsessive-compulsive disorder is an illness that is defined by intrusive thoughts that produce uneasiness, apprehension, fear or worry, that are most commonly demonstrated through repetitive behaviors aimed at reducing the driving wave of anxiety.

It often works. But it often, also, screws up the lives of people who suffer from the disease. As one client puts it, “It’s a monkey on my back, one that I can’t survive with and I cannot survive without.”

One of the common misconceptions about OCD is that those who suffer from it are ridiculously clean. In fact, may people who OCD are hoarders – the behaviors are repetitive and are designed to help them manage their fears and anxiety. Others have trouble doing things like walking on cracks in the sidewalks or other strange behaviors that sooth them but can infer with their lives (think, Mr. Monk). Often, like Mr. Monk, the symptoms come on or come on stronger after a severe emotional or financial crisis. It can boarded on paranoid and even psychotic in its presentation, if not its true symptomology.

Despite people with OCD being out of the norm, it’s not as rare as it might seem. It is the fourth most common mental disorder, diagnosed nearly as often as asthma and diabetes.

Luckily, there are some excellent medical treatments for OCD.

OCD vs. OCPD and Autism Spectrum Disorders

Not everyone who presents with the symptoms of OCD have the illness. Many actually have autism spectrum disorders or the perhaps even more tortuous illness of obsessive compulsive personality disorder or, frankly, no pervasive or persistent disorder at all.

Autism spectrums disorders are illnesses of executive functioning. The resulting social skills problem, difficulties with nonverbal cues, time management problems, organization problems and prioritizing problems often lead to a lot of anxiety. People with autism spectrum disorder also often have restricted and repetitive symptoms.

OCPD is, frankly, the same nightmare as OCD with the added twist built on top. As one National Institutes of Mental Health publication puts it, “OCPD has some of the same symptoms as [OCD]. However, people with OCD have have unwanted thoughts, while people with OCPD believe that their thoughts are correct.”

The belief complaints relationships, often leads to significantly outbursts and a series disinterest in seeking help. These often leads to painful battles with friends and family, who walk on eggshells with people who have OCPD. People with OCPD are more likely than people with OCD to have an obsessive need for cleanliness and over-attention to details. Thing to get black-and-white really fast and there is often little room for other opinions.

Several other disorders, including bipolar and avoidant personality disorder and dependent personality disorder, have significant symptoms of anxiety, but in bipolar it tends to be affective – mood related – and avoidant anxiety tends to play out in, well, obviously, avoidance, and dependence tends to be focused on fears of being abandoned.

It’s worth checking out other anxiety disorders, such phobic disorders (specific fears of spiders, water, wholes, or anything else), panic disorders (focused on full-blown panic attacks), agoraphobia (fear of panic attacks that are so great that people avoid people, places and things). Personality disorders should also be examined, such as paranoid personality disorder (delusional anxiety) and borderline personality disorder (fears of abandonment).

If there is a point here, if you are feeling that stress if impacting your functioning, it’s a jungle out there it is worth it to find an expert to guide you through the vines and the trees.

Jayson Blair is a certified life coach and can be reached here.