Book Review: The Kevin Show by Mary Pilon

In this impressively well written book – I may have to steal a few of her cool phrases, like when she discusses situations in which people walking on eggshells start to feel more like they are walking on landmines – Mary Pilon tells the story of Kevin Hall and his family. Kevin Hall was a championship sailor who on one occasion made the Olympic Team, although he did not win a medal. At the same time, he struggled with Bipolar Disorder. The real illness, not what passes for bipolar disorder these days.

The author’s discussions of what went on inside of Hall’s head during a manic episode are some of the best I’ve ever seen. After reading them, readers will know that this has absolutely nothing in common with normal human thinking. After coming down off of a manic high, a sufferer knows that. Although they may question themselves about the “reality” of what they had experienced during an episode, it still seems to them to be bizarre and alien.

The book also does a great job of describing the traumatic effects on parents, spouses, and siblings in having to deal with a family member with a major mental illness – especially one who is not always cooperative with treatment but doesn’t let them know when he goes off his meds.

Hall’s delusion when manic was that he was some part of a larger “Show,” run by some all-knowing “Director”  - sort of like the movie “Truman Show,’ which indeed is mentioned several times in the book -  in which he is meant to save the world by interpreting various “signs” in the environment. The signs could be things he happened to see in the environment, unusual coincidences like his having been a college classmate of one of the doctors who treated him, song lyrics, or passages in various books he liked to read.

Unfortunately the author, who seems only to have a limited  familiarity with mental illness and, in particular, the treatment of manic-depressive illness, falls a bit into the trap of starting to wonder if it may just be some variation of normal. After all, with the rise of Instagram, selfies, and social media, everyone is seemingly thinking of themselves as in some sort of show and as having an almost national presence in the minds of others.

Mary Pilon

Not only that, but the author adds that certain delusions are more common in certain cultures than others, and some only seem to exist in a single culture.

In fact, the difference between psychotic delusions and false beliefs that are due to groupthink, everyday human foibles, wishful thinking, and just plain kidding oneself is colossal and not in the least bit subtle. Of note is that the author spends almost no time describing Hall’s thinking during periods of bipolar depression. She only mentions one episode in which he maintained that he was depressed but not delusional - but we do not know if he ever experienced a psychotic depression.

Either way, when depressed, it is mentioned almost in passing, he believed the exact opposite of what he felt while manic – that he was a born loser, loony-bin screw-up who was worth absolutely nothing despite his fairly spectacular accomplishments in love and work while euthymic (neither manic or depressed – in other words, normal).

Hall kept going off his medication because he felt that it was drugging the real him, which is why he kept having recurrences. While I obviously can’t say for certain anything about his reasons for stopping his treatment, the frequent reason bipolar patients discontinue their meds is that mania feels so good in so many ways that normal feels like down to many sufferers, and they want the high back.

Another possibility is that he was taken off lithium -  which generally does not make people taking it feel drugged – not because it was ineffective but because the doctors thought it was ineffective when in actuality he had stopped taking it or his blood level was too low. Good doctors monitor lithium blood levels.

He was apparently put on the antipsychotic Haldol at one point, which definitely does make people feel drugged. Antipsychotics, while they do prevent mania, should only be give in acute mania (because it takes time for lithium or depakote to kick in) – and then discontinued after the other drugs start working. Or used indefinitely only if all other options fail or are not tolerated. The author does not really tell us any details about Hall's treatment.

And what about the cultural aspects of delusions? Well of course delusions concern things that people with the disorder are familiar with. You can’t think the CIA is following you around with ray guns if you have never heard of the CIA or ray guns. And just like with Alzheimer’s disease, in which underlying personality traits affect the expression of impaired memory issues and cognitive confusion, they affect the content of delusions as well. 

Pointing out the cultural differences as a possible reason that bipolar is not a real brain disease is a bit like doing the same by pointing out that the delusions of Japanese people are expressed and thought about in the Japanese language, while the delusions of Spanish people are expressed and thought about in Spanish.

Book Review: Unhinged by Anna Berry

I breathe you in again just to feel you
Underneath my skin, holding on to
The sweet escape is always laced with a

familiar taste of poison

~ Halestorm

In female patients with borderline personality disorder (BPD), a behavior pattern is sometimes seen in which the woman quickly gets involved with a seemingly charismatic but at base highly narcissistic male. At the beginning of the relationship, it's love at first sight. There is a whirlwind romance in which both partners seemingly have found their soul mates, and love is professed - occasionally with even a hasty marriage proposal, sometimes within just a couple of weeks. The couple spends all their free time together and can not seem to get enough of each other either physically or mentally.

Before too long, however, the man reveals his true nature. He usually becomes extremely controlling, hyper-jealous and possessive. He wants to know where the woman is every second, and tries to isolate her from her friends and family. All the while, he may lie about his own whereabouts and compulsively cheat on the woman. Not infrequently, he becomes physically abusive to her.

Alternatively, the seemingly exact opposite may happen. Without warning, the man seems to lose interest in her entirely, but nonetheless continues to string the relationship along for a considerable period of time.

In many such cases, after the couple finally breaks up, the woman repeats a nearly identical pattern with another man. She never seems to learn from her mistakes, and denies that she has ever seen any red flags that indicate that things might go awry.

What on earth is going on in the mind of such a woman?  In her new book, author Anna Berry  (a pseudonym) does a marvelously detailed, brilliantly written, and entertaining job of describing her experiences with instances of her involvement with three such men. The memoir is an excellent introduction to the inside of the head of someone like her.

In another part of the book, she describes an experience in which she sort of toys with a psychiatry resident serving as her therapist, demanding that he help her to get back a guy who has treated her like crap and then dumped her. The therapist persists in gamely confronting her about how obviously ill-advised and self-destructive such a course of action would be, if it were even possible.  

As described by the author, the resident seems to be following the suggestions of James Masterson, one of the early psychoanalytic pioneers in the treatment of BPD, to confront, confront, and confront some more. Such confrontations are supposed to be done empathically, however, and in this the therapist falls short, at least in the descriptions of the author.

At some point he even tells her she is a hopeless case - something a therapist should never say to a patient even for effect. She is often snide and sarcastic to him in therapy, yet she continues to see him and even feels abandoned when he has to move away.

The author eventually got herself out of her self-destructive lifestyle and then does pretty well for herself. So what is her explanation for her earlier, crazy-sounding behavior?  

Well, she says it was because she was (and still is) both mentally ill herself, and comes from a crazy family. She at times uses the word delusional to describe herself, and also states categorically that she had brief psychotic episodes - although as I will discuss, from what she describes in her writing, she never once says anything that would clearly illustrate a delusion, hallucination, or any other evidence of psychosis. What she describes so well is something else entirely. So why, even though she does things that seem crazy, does she insist on labeling herself psychotic?

Having never evaluated the author myself, I can only guess, although I certainly can speculate and offer a possible hypothesis. More on that later.

The confusion about whether the author is mentally ill or just self-destructive arose when I was approached by the publisher to write this review.  Initially, it sounded like the book was about the difficulty in growing up in a family with a parent who was chronically and persistently mentally ill, possibly schizophrenic. 

While having a psychotic parent can certainly create family dysfunction and personality problems in offspring, it also sounded like the author herself was struggling with psychosis, and psychotic illnesses per se are not the main focus of this blog. When I asked them for clarification on this, the answer I got did almost nothing to clearly answer my question.

In the book, the patient discusses her own diagnosis, and implies that BPD was the closest thing in the diagnostic manual, the DSM, to what she had. Nothing in the book would cause me to doubt that proposition. She also discusses how she was also diagnosed by different mental health practitioners with a different psychiatric disorder almost every time she saw a different clinician - clinical depression, bipolar disorder, bipolar II, multiple personality disorder, episodic depression, seasonal affective disorder, dysthymia, cyclothymia, anti-social personality disorder, histrionic personality disorder, schizotypal personality disorder, and post traumatic stress disorder.

Her conclusion from having had these different diagnoses was that people just don't fit neatly into the DSM diagnostic boxes. While that is somewhat true, and while it is also true that people can have more than one psychiatric condition (comorbidity), it seems that in her case these labels were applied to her when she in fact did not actually meet the diagnostic criteria at all. She cannot be bipolar if she never had anything resembling a manic episode, or be histrionic when she is primarily an introvert who usually hates to be the center of attention, or have seasonal affective disorder and be depressed at any time of year.

The diagnosis of the author's mother is rather obscure in the author's descriptions. Her brother clearly has severe schizophrenia, and in the beginning of the book it sounds as though the mother did too.  She clearly had psychotic episodes. At one point she throws a lot of the possessions in the house out because voices are telling her that the objects are dirty and if she doesn't throw them away, everyone in the family will get sick and die.

As the book progresses, it eventually becomes clear that the mother's psychotic episodes are episodic and accompanied by her talking non stop and staying up without any sleep for days at a time. Her psychotic episodes would be exacerbated by prescription drug abuse and alcohol - she would often get large quantities of benzodiazepines and other controlled substances from three different free clinics that never communicated with one another. Again, without examining her myself, true bipolar disorder would be the most likely diagnosis if these descriptions are accurate and complete.

Clearly growing up in a chaotic household had a bad effect on the author's mental stability, particularly as she was neglected quite a bit. There often was no food in the house. Dad was apparently too busy having sex with his mistresses openly in the house, with the kids there, to go to the grocery store.

But has the author ever been delusional? Well maybe, but not by her own descriptions in the book. What she describes as being delusional is really a description of her lying to herself while knowing the truth deep down. A real delusion is believed totally and without any doubt, and is certainly not shared by anyone else like a manipulative boyfriend. This is an essential distinction.

In describing her rush towards involvement with one of the problematic men, she says she "could have seen the warning signs a mile away" (p.29).  Although she does not explicitly say that she did not see them, it sounds like she made a concerted effort not to.  On page 74, she writes, " I still didn't have the insight to recognize my destructive relationship patterns, but I can feel the impending doom approaching deep in the pit of my stomach, the way a seasoned sailor can feel approaching storms in his very bones."

That clearly sounds like it was not insight into her relationship patterns that was lacking, but rather that she had decided not to think too much about them. Last time I checked, stomachs can't really think.

On page 87, she describes red flags going up in her brain, but then shrugging her concerns off.  Again, not a psychotic process. She also peppers the book with phrases such as "passive aggressive cry for help and state of denial." Not a psychosis.

She describes her "voices" as almost psychotic hallucinations, but they sound a lot more like the "tapes" we all have running in our heads left over from childhood that tell us what to do and not to do. They are not described as completely external voices like the ones we all hear every day coming from other real people. The hallucinations of psychosis are more like real external voices than inner thoughts.

The first clue that she had never been psychotic was actually a beautiful description of a person with BPD's inner experience - way back on page 5: "...the day-to-day torture of having to create inner and outer selves simultaneously, and maintaining both convincingly...perfect real world training for a professional actor."

So why does she keep telling herself how mentally ill she is? Well, one possibility is that, coming from a family where mental illness is sort of the norm, these thoughts provide her with a sense of belonging and familiarity. Those are powerful needs for most people. Again and again, she uses the same words to describe both herself and her mother, as if their psychiatric experiences were actually far more similar than they really were.

But of course she would be conflicted about thinking herself to be crazy, because, deep down, nobody really wants to be or thought of by others in that way. The author often lived in fear that someone would find out how crazy she was - before demonstrating it to them in spades.

On page 200, she indicates that one of the most important lessons she learned from her psychotherapy was "I am not my parents." More accurately, she probably learned she did not have to be like them. Her mother and brother would never have recovered the same way she did with just the treatment she eventually received that was helpful to her. 

Peter Breggin Goes Off the Deep End

Peter Breggin

Peter Breggan is a psychiatrist who is often highly critical of the use of any and all psychiatric medication, which makes him the favorite psychiatrist of the rabid anti-psychiatry movement along with Tom Ssazz. 

For some of these zealots, it is very understandable why they hate psychiatrists so much.  As anyone who reads my blog knows, incompetent psychiatrists or those docs who have been brainwashed by big Pharma often do a lot of damage to patients through misdiagnosing them, using inappropriate medications, and/or not monitoring their patients for side effects.

I cannot blame such victims for having a highly emotionally charged negative attitude towards my entire profession. 

Still, that does not make everything they think correct.  In fact, it often kind of impairs their ability to be objective about psychoactive substances.

Personally, I always felt that Breggin has used half truths to justify some of his opinions.  But now I think he has gone completely off the deep end. 

After reading what follows, I have this to say to anyone who still thinks he has a shred of credibility: You should look into joining the Flat Earth Society. You’d fit right in.

A news article by Phil Willon of the Los Angeles Times appeared on June 12, 2012, with a follow up story the very next day and again on June 21.  I quote parts of the three stories:

“A San Bernardino County prosecutor Tuesday urged a jury not to be swayed by testimony that the antidepressant Zoloft put a former Westminster police detective in a fog that made him not responsible for kidnapping and raping a waitress in 2010. Deputy Dist. Atty. Debbie Ploghaus called the so-called Zoloft defense, backed by a psychiatrist's testimony, "a bunch of baloney" and a desperate attempt by Anthony Nicholas Orban to sidestep overwhelming evidence against him.

Orban was identified by the victim, was implicated by his best friend, was captured on security video footage at the scene of the attack and left his police service weapon, with his name on it, in the victim's car. Ploghaus told the jury that while bar-hopping in Ontario before the kidnapping, Orban groped a woman's chest, grabbed a man's crotch and repeatedly texted a former girlfriend hoping for an afternoon tryst. "He was a highly trained officer who wanted to have sex. He had sex on the mind. Don't forget that," Ploghaus told jurors in her closing argument.

The Westminster detective is accused of abducting the waitress, then 25, as she walked to her car after a Saturday shift at the Ontario Mills mall. His police service weapon drawn, Orban forced the victim to drive to a self-storage lot in Fontana, according to authorities. The victim told the jury that Orban sexually brutalized her in the parked car, hidden behind tinted windows, as people walked a few feet away.

At one point, Orban snapped pictures with his cellphone, telling her to "smile for the camera." He chambered a round in his semiautomatic pistol, shoving the barrel deep into her mouth as tears rolled down her cheeks, she said. "He said if I cried, he would kill me," the victim told jurors. "Then he pulled the gun out and said, 'I think we'll continue this in the desert.'"

Orban had shared eight margaritas and two pitchers of beer with a friend, and was seeking sexual encounters before he kidnapped the victim at gunpoint and made her drive to a Fontana storage facility, where he raped her, Ploghaus told jurors.

Orban's attorney, James Blatt of Los Angeles, said the assault ran counter to a life spent protecting community and country as a police detective and a Marine veteran of the Iraq war. The only plausible explanation for the defendant's behavior, Blatt argued, was the potent effects of Zoloft, which sent Orban spiraling into an "unconscious" delirium.

"At the time he was not aware, not aware of the torturous things he had done,'' Blatt told the jury…The victim sat in the front row of the Rancho Cucamonga courtroom, clutching a friend's hand, as the prosecutor recounted her testimony that Orban rubbed his weapon against her face during the attack.

Now here’s the relevant part:

The defense relied on Dr. Peter Breggin, a New York psychiatrist and critic of psychotropic drugs who has testified in other cases across North America. Breggin said he believed Orban suffered a psychotic break from reality shortly before the kidnapping and was in an unconscious state of delirium, void of control or memory, during the attack. "I don't even think he knows he's tormenting her," Breggin testified. "He would not under any circumstances behave like this if he was not driven over the edge by the drugs." Orban had temporarily quit taking Zoloft, prescribed by his psychiatrist, then resumed it at full dosage five days before the attack, which Breggin said sent him into a state of manic psychosis.

Breggin testified that Orban had stopped taking the prescribed antidepressant, then resumed it at full dose, provoking a psychotic break during which he was "delirious" and not fully aware of his actions.

The prosecutor criticized Breggin as "intentionally misleading" and told jurors that the scientific community rejects his medical theories. Ploghaus' medical expert, Dr. Douglas Jacobs, an associate clinical professor at Harvard, testified that Zoloft has been prescribed to millions of people and proved to be safe. There has been no evidence that Zoloft causes delirium or unconsciousness, he said.

While antidepressants can definitely cause someone who actually has bipolar disorder to become manic (more on that near the end of the post), and even though Breggin used the word "manic" in his testimony, symptoms of mania were not what Breggin and the defendant testified to.  


They said he was in an unconscious state of delirium.  That is not and has never been alleged to be a symptom of mania at all.  And the degree of the planning and execution of the series of events involved in the rapes is entirely inconsistent with delirium, which is defined as a disturbance of consciousness - reduced clarity of awareness of the environment with reduced ability to focus, sustain or shift attention - and is usually caused by metabolic abnormalities due to a medical condition or to an overdose of certain drugs, Zoloft not being one of those drugs.  


The actions of the defendant seemed  pretty focused to me! In fact, it sounded as if he were mentally quite sharp even though he had mixed the Zoloft with a lot of alcohol. (Being drunk is not at all the same as being delirious).


And then there was this from the defendant:

Within days, he said, he was overwhelmed, hearing voices at night, contemplating suicide and fantasizing about killing his wife and dog.

Sounds more like depression to me, not mania.  Perhaps a “mixed state,” but those are fairly rare.

And the kicker: the prosecutor questioned the defendant about parallels between his testimony and similar accounts in a magazine and book by a well-known critic of psychotropic drugs.  Orban acknowledged reading both works, but denied they had influenced his testimony.  Oh, and the critic who authored the book?  Breggin!


And now to the issue of antidepressant-induced mania. Apparently no one else testified that the detective had any history of having the disorder.  If he were bipolar and Zoloft was going to make him switch into mania, it would have most likely already happened when he was first taking the drug – not when he resumed it after a short break.  Resuming a “full dose” may lead to other side effects, but not that one.  As far as I know, the ability of antidepressants to kick someone into a manic state is not dose-related.

Besides, very few patients in a manic state become violent rapists. 

And patients in a manic state still can still tell right from wrong unless they are out-of-their-mind psychotic.  There was apparently no evidence he was delusional.  (If there is, then I might have to take back some of what I am saying about this case, and, if it turns out that the detective had a grandiose delusion that raping the woman would somehow save the world from an alien invasion, owe Dr. Breggin an apology).


As to the rape being "counter to a life spent protecting community and country?"  As we all know, soldiers in Iraq and police are never guilty of violent behavior.  Before he died, you could have asked Rodney King.  And I suppose we know for a fact that this was not just the first time he got caught.

What this is, barring further revelations about the defendant’s history of mental illness, is a variation of “The devil made me do it.”  Or perhaps a version of assassin Dan White’s defense in the case of his murder of two San Francisco politicians, “He did it because he was depressed, as evidenced by the fact that he was pigging out on a lot of Twinkies.”

Dan White assassinated  San Francisco Mayor George Moscone and  Supervisor (and gay hero) Harvey Milk on November 27, 1978, and was sentenced to only seven years

Apparently, the jurors also thought it was a stupid defense:

A jury of eight women and four men deliberated less than a day before dismissing that defense and finding Orban guilty of kidnapping, two counts of rape, two counts of forced oral copulation, two counts of sexual penetration with a foreign object and one count of making a criminal threat.

Orban is now facing a sanity hearing to determine whether he knew the difference between right and wrong at the time of the attack. He almost certainly faces a life prison sentence if the jury determines he was sane. If declared insane, he would be sent to a state mental institution for treatment, and later could be released. The same jurors have been impaneled for the sanity proceeding.

"What it comes down to is whether, at the time of this incident, he understood the difference between right and wrong," Orban's attorney, James Blatt of Los Angeles, said outside the courtroom. "I believe [the jury] will keep an open mind in reference to the sanity phase."


Addendum (6/27/12): The jury rejected the insanity defense, although some prosecutors apparently did blame the alcohol (rather than the Zolfot) for his "mental fog."  That's nonsense, too, considering the intricacies of his actions during the attack.  Looks like he had a lot of tolerance to the booze.