Bipolar 2 From Inside and Out

Posts tagged ‘mental illness’

What Is Intimacy?

The first thing you probably think of when I say “intimacy” is “sex.” That’s natural. Most people do. Sex is a particular kind of intimacy, but it’s not the only one. Others can be just as intoxicating, fascinating, and compelling. They can be a great way to bond with another person and provide fulfillment.

You may think that treatment for mental illness will take intimacy away from you. I’m here to tell you that you can still have intimacy with another person. It may or may not be sexual intimacy, but it’s valuable all the same.

Intimacy is a bond between two people. While it can be caused by sexual attraction, we all know how quickly a sexual bond can fade or disintegrate. Sometimes, a couple can have another form of intimacy once sexual intimacy is no longer possible. And, of course, there are couples who can maintain sexual intimacy until quite late in life.

Another way you can bond in a kind of intimacy is through shared trauma. As the saying goes, shared pain is halved and shared joy is doubled. The trauma doesn’t have to be a natural disaster, though that can certainly bond people who show kindness to each other. Once, I was sitting next to a man at a concert when a song touched a deep nerve and made him dissolve in tears. I reached for him and held him until the song was over. That started a deep friendship that has lasted for decades.

I’ve also found that shared symptoms can lead to a kind of intimacy. If both of you find your legs twitch when you’re not paying strict attention to stopping them, if you’re taking the same medications or have the same adverse reactions to them, or if you’ve both been gaslighted, you can find yourself exclaiming, “Hey! You too!” It helps to know that you’re not alone in your pain.

Humor, especially dark humor, is another way of sharing intimacy. It’s that shared joy principle. One way that’s worked for me and others is to use quotations from funny movies or songs—Young Frankenstein, Monty Python and the Holy Grail, Buckaroo Banzai, and Weird Al Yankovic are among my go-tos. Puns. Bad jokes. A good, shared belly laugh is a powerful bonding experience. It can lead to endless conversations that reveal lots about another person.

Some couples who have explored these alternative kinds of intimacy find they can live without traditional sex or can find sexual fulfillment solo. Those are valid choices, too. Even people who have sex with a partner can use sex toys and other aids from time to time. They’re easily available on the internet, so you don’t even have to go to a potentially embarrassing sex shop.

Of course, you might point out that these kinds of intimacy require meeting people, and going out may be something that frightens you. Fortunately, technology provides answers. With telephones, computers, and the internet, you don’t have to be in the same room with another person to develop intimacy. You can even turn off your computer’s camera so your new friend won’t see you. I’ve corresponded with a kindred soul via old-fashioned snail mail. And it’s something you can work on with your therapist if non-sexual intimacy is your goal.

If sexual intimacy is what you want, however, you can start with these techniques and work up to the big event. Having a solid foundation for touch, foreplay, and sex will make the process go more smoothly. Leaping into a sexual relationship without exploring other kinds of intimacy can leave you open to disappointment, a mismatch of sexual styles, and a devastating ending. Taking your time and finding a partner who doesn’t pressure you for sex will help you achieve sexual fulfillment when you are truly ready for it.

Intimacy with sex? That’s another topic for another week.

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Was My Ex a Narcissist? Maybe Not

I know I’ve said my ex was a narcissist. His pleasures and interests were the only ones that counted. If I said that I liked something, like a certain style of music or kind of food, he said, “Eat shit. Fifty million flies can’t be wrong.” He talked about how important his honor was. He invented something that I would collect, just so he could pre-select gifts for every occasion. To quote the song “My Baby Thinks He’s a Train,” “He dragged me ’round just like an old caboose.”

But was he a true narcissist or simply a self-centered asshole?

Well, he was never diagnosed as a narcissist. The only time he saw a therapist was when we went for couples counseling. He aligned himself with the therapist. He made it seem like I was the crazy one, and he was only there to help me because he loved me so much. (That was gaslighting, not narcissism.)

And that’s an important point. Only a psychiatrist can diagnose a true narcissist: someone who has narcissistic personality disorder.

What’s Narcissistic Personality Disorder?

The Diagnostic and Statistical Manual-V (DSM) has a list of criteria that add up to Narcissistic Personality Disorder. There may be changes in the DSM-VI, currently being written, but for now, in order to be diagnosed, a person has to exhibit:

A pervasive pattern of grandiosity, need for admiration, and lack of empathy, as well as five or more of the following behaviors or traits:

grandiose sense of accomplishment

My ex: Check. Always had to be the smartest person in the room, though he never completed his doctorate. Thought his middle name, Albert, was a reference to Einstein.

preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

My ex: Probably not. Content with a public service government job; bounced from relationship to relationship.

believes that he or she is “special” and unique and can only be understood by or should associate with other special or high-status people (or institutions)

My ex: Pretty much. Only associated with neighbors who could do something for him; felt others had lower status.

requires excessive admiration

My ex: Check. Wanted to be known as the smartest, funniest, most talented, skillful, and well-loved.

a sense of entitlement

My ex: Not sure. Regarding sex, intimacy, and attention, yes. In other ways, not so much.

interpersonally exploitative

My ex: Big check. Put people in “can’t-win” situations.

unwilling to recognize or identify with the feelings and needs of others

My ex: Check. See above.

envious of others or believes that others are envious of him

My ex: Not really, or didn’t say so.

arrogant, haughty behaviors and attitudes

My ex: Check. Corrected others’ pronunciation; got to define “quality” for others.

Explanations

By those criteria, my ex might qualify as being among the 1% or 2% of people who have a Narcissistic Personality Disorder—if diagnosed as such by a psychiatrist, not through the lens of only one person—me—who is not truly qualified to assess him. I can’t truly say that he had the Narcissistic Personality Disorder, only that he exhibited some narcissistic traits when I was with him.

There’s a possibility that we were simply incompatible, or that I exhibited unhealthy traits too, or that he was fine in relationships with others, or that he was simply a selfish asshole and nothing worse. If you were to believe social media, 30% to 40% of bad relationships were caused by a narcissistic partner.

There are different degrees of bad behavior. A person can be a gaslighter without being a clinical narcissist. They can be abusive. They can be cold and unforgiving. They can behave so badly that you think of them as abusive or narcissistic. None of those are good things. But calling someone a narcissist is giving them what is essentially a meaningless label, or at least one that says, “I suffered when I was with them.”

So, I did suffer. My ex treated me and others badly. But as for his being a real-life Narcissist, the jury remains out.

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Global Wins for Mental Health

Most of us know quite a bit about the U.S. mental health system, if it can be called that. We know about its successes and its failures, its help and its harm, and its practitioners and patients. But what about other countries? What large and small actions do they take to help people with psychiatric symptoms or disorders in their countries?

First, we know that approximately 78 countries around the world have socialized medicine or some form of universal health care that includes psychiatric services. Some have reported long wait times to get help, but others are easier to access. Most psychiatric drugs are subsidized. And the societies function in ways that foster mental health. Let’s look at a couple of programs that seem to be working.

Denmark

Denmark has a program designed to fight the stigma that accompanies mental disorders. It’s called One of Us.

Giuseppe Parlatore, who lives with paranoid schizophrenia, felt the stigma himself when a former teacher assumed—and said to him—that he must be either self-harming or violent and dangerous to others. He felt shame.

Parlatore, who was diagnosed in 2009, has worked hard to cope with his symptoms and carve out a life for himself. Now he is a leading mental health advocate, working with officials to lessen the stigma of mental disorders.

One of Us works with people called ambassadors, who have mental illnesses, to work with schools, police, and hospitals, sharing their stories and focusing on recovery. The emphasis on hospitals and police, they feel, is necessitated by the fact that personnel mainly see mental patients when they are in crisis rather than when they are coping better with their illnesses.

The Danish Health Authority also has a department of prevention and inequity. Anti-stigma campaigns are a part of the Ministry of Health. They hope to see lasting effects among the population, rather than just short-term upticks in awareness. The Danes see social contacts as more likely to change opinions than education alone.

Still, the battle against stigma requires persistence. Parlatore says that for him, it’s a “generational project.”

Japan

In Japan, there is a thing called kodokushi or “the lonely death.” The population of Japan is aging, and many older adults have little to no social contact. They can die alone and not be discovered for a long time. Social isolation leads to stress and loneliness. But a program designed to encourage physical health is having an effect on the elderly people’s mental health as well.

The “yogurt ladies” started as a way to promote health by selling yogurt to households. They were easily identifiable by their blue uniforms and bicycles. They succeeded very well in making people aware of gut health.

But gut health is also related to stress and chronic loneliness, two factors affecting mental health. Social isolation is, in turn, involved with gut microbiome diversity.

Loneliness is taken seriously in Japan. The government even includes a Ministry of Loneliness, as well as a task force on social isolation. The yogurt ladies provide weekly check-ins, a friendly face, and a chance to interact with someone. They see themselves as people who look out for others. Their services are a practical factor in maintaining gut health, but they perform an important function in reducing social isolation and preventing the “lonely deaths.” The lift they provide weekly is an important factor in maintaining mental health for the aging population of Japan.

Why don’t we have programs like this in the U.S.? I think you know the answer.

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Self-Care Definitions

It used to be that when you said “self-care,” you were talking about spa days, shopping sprees, mani-pedis, indulgent desserts, or wine tasting. Or, as Marge Simpson so eloquently put it while ensconced in a bubble bath, “a banana fudge sundae! With whipped cream! And some chocolate chip cheesecake! And a bottle of tequila!”

Pretty quickly, that definition of self-care was recognized as a bougie, upscale fantasy available only to a wealthy person. Not to say that it isn’t relaxing or restorative, but it’s clearly not for the majority of those overwhelmed, traumatized, or otherwise suffering psychologically. They need something more than a beauty regimen and a spending spree.

A Better Definition

The next definition of self-care adds up to basic physical health and hygiene. You know, all the things you’re supposed to do to lead a healthy life: eat right, hydrate, get enough sleep, take showers daily, walk daily. And the things we’re supposed to do for mental health and hygiene: get outdoors, reach out to friends and family, take your meds, exercise, go to therapy, journal, practice affirmations.

All those actions and activities can help your mental health, it’s true. But they work best if you’re already fairly stable. There have been times in my life when all I could do was eat Cocoa Puffs and take my meds. When you can’t even get out of bed, telling you to get out of bed isn’t likely to work. It can even make you feel worse because you know you should do those things, someone’s telling you to do those things, and you’re so deep in the hole that you can’t do those things. Then you beat yourself up for that.

The Self-Care Box

I think that when it comes to self-care, you should start small. When you do begin to see a ray of light, take note of the things around you: comfort objects, things that have distracted you and pulled you out of your misery for even an hour or two in the past. Surrounding yourself with these items or knowing where to find them is, to me, a valid form of self-care.

I’ve seen recommendations that you prepare a self-care shoebox containing the things that soothe your five senses: ones that you can touch, taste, hear, see, or smell. That’s a good idea, but the things that soothe me don’t fit in a box, especially my blue blanket, my cat (just try to put a cat in a box not of his own choosing), a DVD player, and discs of The Mikado, The Pirates of Penzance, and The Three (and Four) Musketeers. I could probably fit a bag of ginger snaps in a self-care sensory box.

Instead, I just make sure I know where these things are. They’re all in my study (except sometimes the cat), which is, in effect, a large sensory box itself. My husband knows my self-care regimen and steps in as needed to provide the items I don’t have. And, after I’ve restored myself a bit, he’ll try to coax me out of the house with the promise of lunch at a favorite restaurant. Or even Waffle House, which is very close by and doesn’t require much effort, like getting out of sweatpants and into a skirt.

If you don’t have a study, keep your comfort objects in one room of your house: bedroom, living room, basement, rec room, or wherever. The important thing is to know where to find them when you need them.

Today’s Self-Care

I do journal, or at least I write in my blogs and post them weekly. When I’m overwhelmed, my schedule keeps me tied to the world. I know I have to have something written by Sunday at 10:00 a.m. It motivates me to get out of bed and kick my brain into gear. It’s less random than journaling, which can easily fall by the wayside. And if I’m still depressed, anxious, or overwhelmed, I can write about that. Thanks to my bipolar disorder, I have a ready supply of topics.

Right now, today, I have my blue blanket and my word processing program. The cat is in the doorway and likely to curl up on my comfy chair or my lap and sleep. I have a bag of ginger snaps on my desk and more nutritious things like fruit within easy reach. I’ve taken my morning pills, which live in a bag that hangs on the doorknob near my bed. I’m set for the day. I don’t need cheesecake or tequila.

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AI and Mental Health Concerns

I read a lot of news and commentary regarding mental health and mental illness. There are sources I return to again and again because of the quality of their reporting and the consistency with which they address difficult topics. Two of my favorite sites for timely information are The New York Times and MindSite News.

Here’s a brief look at what they’ve published recently on the topic of AI and how it impacts mental health.

AI as Therapists

AI in general, and chatbots in particular, are being used to assist human therapists or even take their place. It’s true that therapy bots and chatbots are available whenever a person needs their services. There’s no waiting for an appointment.

But what is happening during those “sessions”? Many of the therapy bots use “generative AI,” which means that they can answer questions with output they have gleaned from thousands of input sources available throughout the internet. There is at least one therapy bot, however, that uses responses that have been vetted by actual human therapists. It’s designed to provide discussions of a problem or emotion between in-person appointments. The user gets a hybrid therapy experience that includes follow-up questions, affirmations, or short lessons.

General-purpose chatbots like ChatGPT can respond to sensitive questions about topics such as self-harm with responses that may encourage such behavior. Teens have found ways to avoid the safeguards that chatbots are supposed to have regarding these topics.

One thing that therapy bots cannot do is offer a diagnosis. They may be better used for persons with mild symptoms.

Chatbots as Friends

AI chatbots can also take the place of sympathetic friends who can provide connection and conversation. Paradoxically, however, this can lead to greater isolation for users whose human contacts are replaced by AI. You can’t share a meal with a chatbot, although you can chat virtually on your phone while you’re in a café. (Not that I recommend this.)

Some chatbots provide companionship as they have conversations with users who feel isolated. There are drawbacks, however, as some of the bots offer paid upgrades to the program or in-app purchases, including “gifts” for the online “friend.”

AI and “Brain Rot”

“Brain rot” has become a euphemism for over-reliance on technology, including computers, smartphones, video games, and especially social media. While most of the concern is focused on children and teens, adults can be afflicted with brain rot as well. After all, grown-ups spend time online for work, communication, recreation, research, news, and other purposes. The working definition of brain rot is a condition of “deterioration of a person’s mental or intellectual state,” or associated with “engaging with low-quality internet content,” without reference to age.

Media, especially short-form video, can reduce a person’s attention span and lower academic performance. Interaction with social media has also been associated with emotional conditions such as depression, anxiety, stress, and loneliness. Experts warn that, so far, they’re talking about correlation rather than causation. That is, they haven’t proven that absorbing short-form video causes the negative results regarding reading, memory, and language, but it is associated with them.

Other Hazards of AI

There have been reports that a few people who use chatbots begin to suffer from delusions. Where before, a person might have eccentric thoughts, using a chatbot can escalate the person to paranoia, for example, or psychosis, suicidal thoughts, or even violent crimes.

ChatGPT faces lawsuits related to harmful outcomes when people use it. While the percentage of people experiencing these ill effects is small, the sheer number of people who use ChatGPT means that the number of people experiencing psychosis or mania may be quite high.

Other, less dire effects are also possible. People who live with anxiety, depression, or OCD can find that the chatbot may provide validation for their symptoms rather than encouraging them to face their problems. A chatbot can also fuel grandiose thoughts by reinforcing them. Or a troubled user may come to rely on the chatbot to help them calm down, which is less healthy than addressing the source of the person’s anxieties.

Of course, chatbots have many positive uses, and not all interactions with them will lead to problems. But both children and adults should monitor their use of chatbots to make sure they aren’t going too far “down the rabbit hole.” A “digital detox” can be good for both adults and children.

If you’re interested in exploring topics like these, you might want to consider subscribing to MindSite News at mindsite.org.

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Unpaid Drug Reps

Eight years ago, I wrote a post about how I despise TV commercials for psychiatric drugs. The New York Times has caught up with me. On February 16th (updated on the 17th), they published a story titled “Should Drug Companies Be Advertising to Consumers?” The article concentrated on drugs advertised to seniors, but what they said holds true for psychotropic drugs as well.

The problems of drugs advertised directly to consumers started in 1997, when regulations covering drug ads were loosened. Until then, drugs had been advertised to doctors who were going to be prescribing them. Then, print ads appeared in magazines and journals targeted to prescribers. In addition, drug reps visited doctors’ offices, handing out drug samples and literature, along with tchotchkes decorated with the drugs’ names. The reps also often brought carry-in lunches for the whole office and sometimes wooed particularly influential doctors with golf outings and other gifts and junkets.

That system had its drawbacks, it’s true, but so does the new one. When it was first allowed, drug ads appeared in consumer magazines, often as multi-page fold-outs because so much information about dosages, effects, and side effects had to be included.

Before long, however, the drug companies started to take advantage of television and the internet. And take advantage they did. As the Times reported, last year, “total spending on direct-to-consumer advertising of prescription drugs topped $9 billion.” Only New Zealand and the U.S. permit direct-to-consumer advertising.

The result is that consumers have become drug reps. The TV ads say, “Ask your doctor if Drug X is right for you.” What happens instead is that patients come in to their doctor and say, “I want Drug X.” And if the doctor doesn’t comply, the patient moves on to another doctor who will provide the requested drug. Instead of investing in a flock of drug reps, the pharmaceutical companies are investing in advertising that replaces many reps with many consumers who know much less about the drugs. In effect, the patient has become the drug rep, trying to influence the doctor to use a particular medication.

TV drug ads are sophisticated. Even the psychotropics have songs and slogans and color palettes, just like the ads for other drugs or indeed, soft drinks or cruise lines. Even the much-touted antidepressant Caplyta, which has had some of the slickest, most attention-grabbing ads, uses the song “This Little Light of Mine,” with slightly altered lyrics. Austedo, for tardive dyskenisia, features the slogan “As You Go With Austedo.” Cobenfy ads, for schizophrenia, sing, “Imagine What You Could Be. Cobenfy.”

The commercials do have recitations of the possible side effects, which are accompanied by tiny type on the screen. Often, the side effects seem to contradict what the drug is for: a bone-strengthening pill has a side effect of “unexpected thigh-bone breaks”; depression and bipolar meds have side effects of suicidal thoughts; one for tardive dyskinesia warns of “body stiffness, drooling, trouble moving or walking, trouble keeping your balance, shaking (tremors), or falls.” And there are other warnings: potentially fatal skin rashes (most likely Stevens-Johnson Syndrome), for example, or harm to an unborn baby.

The manufacturers probably count on the consumers not reading the tiny warnings. (The voice-over sometimes says, “These are not all the possible side effects.”) An ad will say, “Weight gain is not often seen,” but the tiny type says how much weight gain in mathematical terms such as “<.27 percent” that can be confusing to a layperson. If you read the type, you can also find that, for example, other side effects are not mentioned in the lists of possible outcomes. (“You should ask your doctor about these and other possible side effects.”) Some of the studies they quote seem to have reported results after only five weeks–not that the public can be expected to know the scientific niceties. I’m aware that I don’t understand them all myself. There may be aspects I’m not catching.

At the end of a psychotropics commercial, the now-stable person/actor/model engages in a variety of pursuits: being outdoors, playing with children or grandchildren, playing guitar, or taking painting lessons. There’s no indication that the meds may not work without an additional drug or drugs, that they may take six weeks or more to begin working, or that they may have no effect at all. In short, the TV commercials build unrealistic expectations for wonder drugs.

Certainly, many people have found that a drug or “cocktail” of drugs has alleviated their symptoms, though not cured the underlying disorder. I’m one of those people. But my information about my medications came from my doctor, not an advertising agency.

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It’s Mom’s Fault Again

In the 1940s, autism was thought to be caused by the “refrigerator mothers,” who didn’t show enough love and affection to their children and thus made them incapable of interacting appropriately with other people. This theory hung on into the 1970s and was supposedly backed by science. Even Bruno Bettelheim supported the theory.

Later, mid-century, the refrigerator mother theory was resurrected to blame cold mothers for causing their children to be homosexual. (“Overbearing” mothers were thought to have the same effect. In essence, women couldn’t win.) Mothers were also blamed for schizophrenia.

All of these theories have been debunked. It seems they were a reaction to women joining the workforce and relying on childcare to fulfill the child-rearing functions previously provided by stay-at-home moms.

Now the blame-mom theory is back. Mother Jones magazine published an article in the September/October 2025 issue, “No, Moms Are Not to Blame for ADHD” by Chelsea Conaboy, reporting on how the theory has shifted and resurged, and how it still isn’t true.

Dr. Gabor Maté, a guest on Joe Rogan’s podcast, was promoting his fifth book, The Myth of Normal: Trauma, Illness & Healing in a Toxic Culture. During that interview, Maté “explained” that “hyperactivity and poor impulse control develop in particularly sensitive babies who are adapting to stressed parents, especially mothers.” Stressed—read “inattentive” mothers—cause children to “tune out” and “that tuning out is then programmed into the brain.” Women who turn to doctors with questions and lists of their children’s behaviors are “obsessive and overly intellectual.” That is to say, the opposite of the ideal warm, nurturing mother who could have prevented the symptoms in the first place.

Maté’s emphasis on the maternal bond dates back to his first book, Scattered Minds, published in 1999. In it, he said, “All the behaviors and mental patterns of attention deficit disorder are external signs of the wound, or inefficient defenses against feeling the pain of it.” He says he bases his theories on “literature research… on hundreds of patient interviews, and on my clinical observations.” Stephen Faraone, professor of psychiatry, neuroscience, and physiology at SUNY Upstate Medical University and president of the World Federation of ADHD, says that Maté’s science is not cohesive and “cherry-picked.” Faraone also says that Maté’s theories can cause “real harm if it dissuades families from seeking evidence-based treatment, including effective medications.”

Reputable researchers say that ADHD is “highly heritable, with genetic differences accounting for as much as three-quarters of its prevalence.” The fact that rates are rising is more likely due to better diagnosis, especially in girls, who have been underdiagnosed and underrepresented. Maté has acknowledged a heritable component or “sensitivity,” which he says is then unlocked by the family environment.

There are other theories, of course. Secretary of the Department of Health and Human Services Robert F. Kennedy, Jr., attributes ADHD to chemical exposures. Erica Komisar, a clinical social worker and contributing editor at the Institute for Family Studies, says that the theory that parents can cause their child’s ADHD through stressors, including divorce, day care, and the “muddling” of traditional gender roles, is an inconvenient truth.”

It hasn’t passed unnoticed that the theory of maternal causes of ADHD supports the conservative view of what a family is and what a woman’s role in it should be. Stay-at-home moms are more valued because of their supposed innate nurturing nature. How that correlates with theories about “refrigerator” or “overbearing” mothers isn’t clear, since stay-at-home moms can theoretically be either. Working mothers are considered “stressors” that can bring about ADHD.

The take-away from all this? The best current science says that ADHD is largely an inheritable condition and that blaming mothering techniques is outdated and unfounded. The important consideration is diagnosing ADHD in children promptly and getting them valid, science-based interventions and treatment. Mothers and children will always have stressors in their lives, whether the mothers stay at home or not. Singling out working mothers as stressors is unfair.

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Update: The Keto Diet

Almost exactly a year ago, I wrote a post called “Is a Keto Diet Good for Bipolar?” In it, I examined the keto diet, one that involves consuming a very low amount of carbohydrates and replacing them with fat to help your body burn fat for energy. That means you should avoid sugary foods, grains and starches, most fruit, beans and legumes, root vegetables and tubers, low-fat or diet products, unhealthy fats, alcohol, and sugar-free diet foods.

What’s left? Good fats like avocados and EVOO, as well as meat, fatty fish, eggs, butter and cream, cheese, nuts, seeds, low-carb veggies, and herbs and spices.

So, what does that sound like—a diet high in meat and fats that avoids most fruit, beans, legumes, and ultra-processed foods? That’s right: the new upside-down food pyramid instituted by Robert F. Kennedy, Jr., the U.S. Health Secretary.

In that previous post, I talked about studies that examined the keto diet as applied to depression and bipolar disorder in particular. The bottom line I left to WebMD: “The advice from WebMD is that there is ‘insufficient evidence’ to recommend the diet as beneficial for mood disorders. They don’t recommend it as a treatment option. As with any diet plan, consulting your doctor first is a good idea.”

Now, however, RFK, Jr., is touting the benefits of a ketogenic diet as a “cure” for schizophrenia. The New York Times called it “an unfounded claim that experts say vastly overstates preliminary research into whether the high-fat, low-carbohydrate diet might help patients with the disorder.”

In fact, the Secretary said, “We now know that the things that you eat are driving mental illness in this country.” He claimed that an unnamed doctor at Harvard had cured schizophrenia, and talked of studies “where people lose their bipolar diagnosis by changing their diet.” He was apparently referring to a 2019 experiment in which two patients “experienced complete remission of symptoms” with the keto diet. He said both patients “were able to stop antipsychotic medications and have remained in remission for years now.” Dr. Palmer, who originally reported the results, made no comment for the Times story.

The post promoting the claims was taken down from the website when evidence was requested to support the assertions.

The ketogenic diet is popular but difficult to stick to with its emphasis on fats over carbs. It’s up to you whether you try it to treat a mental disorder, but my honest opinion is that you shouldn’t stop taking your meds or doing your therapy. Try the keto diet in addition to them if you want to. Stopping your meds with the help of a physician who can guide you in tapering off safely is essential. Don’t go cold turkey, even if you do think the keto diet might help you. It’s simply not safe.

Unlike RFK, Jr., I’m not giving medical advice, only my opinion. Your mileage may vary. Your primary care physician or psychiatrist knows you and your condition best. Ask their advice and follow it.

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Changes in the DSM?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has gone through changes, and its creators are discussing further changes that need to be made. The DSM-V was updated in 2022 to produce the DSM-V-TR (Text Revision). The new set of changes may result in a DSM-VI. (That’s not an official name, but people are already referring to it that way.)

Over the years, the changes to the DSM have sometimes been made to address a better understanding of what constitutes a mental disorder. For example, homosexuality was listed in the original DSM (1952) as a “Sociopathic Personality Disturbance,” considered a “sexual deviation.” The definition was gradually chipped away according to societal pressure from advocates and a dawning realization that homosexuality was not a mental disorder. It wasn’t until 1987 that the diagnosis or versions of it were completely eliminated.

Autism took a similar path. In the 1952 edition of the manual, autism was categorized under “schizophrenic reaction (childhood type).” It was not recognized as a separate developmental diagnosis on a spectrum until the DSM-III in 1980. Schizophrenia has nothing to do with it, and the newer text reflects that understanding.

Rather than the be-all and end-all of psychiatric knowledge and diagnosis, the DSM-V is better understood as a guidebook that helps practitioners drill down through a puzzling array of symptoms to reach at least a preliminary diagnosis. While the publication date for the newest revision of the DSM is still up in the air, the fact that it needs updating is clear.

So, what changes are in store in the next edition? Well, for one, the American Psychiatric Association (APA) is changing the name of the manual to “Diagnostic Science (or Scientific) Manual of Mental Disorders.” That’s hardly a significant change, given that psychiatry is less of a science and more of a practice (or art). The committees of experts who are doing the revisions will be augmented by people who have lived experience of the various disorders and people who are critics of the current DSM—of which there are many. Among the criticisms is the fact that the manual pathologizes everyday events into psychological disorders. Children’s temper tantrums become Oppositional Defiant Disorder, for example. This medicalization of everyday behaviors may result in overdiagnosis, not to mention overmedication. And it’s particularly true that an ER doctor confronted with someone who has a mental disorder cannot, in the 15 minutes they’re able to spend with the person, tell whether their hallucinations are due to schizophrenia, bipolar 1, drugs, or some other cause.

The new DSM will reportedly change the way it defines diagnoses, from a reliance on symptoms and characteristics to include consideration of environmental, socioeconomic, cultural, developmental, and biological factors. For example, whether a person has experienced physical or sexual abuse in childhood will contribute to trauma diagnoses. It’s hoped that considering the whole person, not just their symptoms, will lead to a better understanding of psychiatric and psychological conditions.

Clarification of diagnoses to include new features or diagnostic criteria, however, can lead to oversimplification, something that will need to be considered in preparing the new edition. Biological features of disorders are supposed to be included, despite the fact that there are no objective tests, such as genetic tests or fMRI, to pinpoint a psychiatric diagnosis. This, of course, may necessitate further revision of the DSM as such testing improves. It’s hard to imagine how a discussion of future advances in diagnosis will help current practitioners until those advances are made. It’s an acknowledgment that even further revisions will ultimately be required.

The insurance industry will also be very interested in the new edition, whenever it comes out. In addition to definitions of the different conditions and lists of symptoms that can be used to make a diagnosis, the DSM also provides billing codes for the various disorders. And, as we know, getting insurance reimbursement for a particular diagnosis is difficult at best unless it has a billing code attached to it.

What the average patient will think about the updated DSM, if they know about it at all, remains to be seen. At any rate, it’s encouraging to think that the psychiatrists’ “Bible” may lead to more accurate diagnoses and better treatments. I just can’t shake the feeling that as soon as it is published, it will already be obsolete, needing ongoing tweaks that won’t be included until such time as another substantial revision is considered necessary. How long will we live with DSM-V (TR), essentially an unfinished work? I suppose at some point, the APA must decide when the DSM-VI, a work-in-progress, is “good enough” to publish.

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A Quick Turnaround—What’s Next?

On Wednesday, it was gone. On Thursday, it was back. Who knows what will happen tomorrow?

Many of us were stunned (if not exactly surprised) when it was announced that federal funding for mental health and addiction services was going to be cut dramatically. After all, other public health agencies have seen their budgets slashed and their grants revoked. It seemed to be only a matter of time until mental health resources were hit. And so it was.

Late this past Tuesday (as in 10:30 p.m.), the Trump administration said it would be cutting approximately $2 billion from programs that deal with mental health services and addiction prevention, treatment, and recovery services. The news went out from the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal agency that oversees these programs, late in the day. The faxed letter about the cuts got to the press from agency employees who remained anonymous.

The New York Times reported that the cuts “would be effective immediately,” explaining only that the services no longer aligned with the agency’s priorities. The letter described those priorities as being to support “innovative programs and interventions that address the rising rates of mental illness and substance abuse conditions, overdose, and suicide.” Among the programs affected would be drug courts, screening and referral services, and other important initiatives serving youth and pregnant and postpartum women. It was a little confusing, as the SAMHSA agency was designed to do that.

NAMI had an immediate response. CEO Daniel H. Gillison said, “These abrupt and unjustified cuts will immediately disrupt suicide prevention efforts, family and peer recovery support, overdose prevention and treatment, and mental health awareness and education programming, along with so many more essential services, putting an unknown number of lives at stake.” He added, “These aren’t just numbers on paper. These are decisions that have real and harmful consequences for millions of people and communities around the country.” A dozen or more NAMI programs instantly lost funding. Among the programs affected would be “numerous education programs, including one that offers mental health training to school staff in grades kindergarten through 12.”

These funding cuts were apparently made without consulting Congress, who are working on an appropriations package, scheduled for the end of the month, that also addresses mental health and addiction services. Members of Congress lobbied strongly against the cuts.

Then, less than 24 hours later, the cuts were canceled, and funding was restored. No explanation was given; the cuts were simply made to disappear. They had been particularly unsettling after President Trump reauthorized the SUPPORT Act in December. It had funded programs for addiction and mental health, including some of the programs that were cut this week.

At the end of January, Congress is supposed to consider a major funding package that includes money for SAMHSA. What it will include appears still to be up in the air.

I guess we’ll see. And be ready to protest, just in case.

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mental health

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