Sunday, June 27, 2010

Lots And Lots Of Questions

One of our blog and podcast followers wrote to us with a few questions. I'm not going to mention the person's name without permission, but they're a pre-med student with an interest in psychiatry. I thought I'd take a stab at some of the answers. Dinah and Roy can chime in with their own thoughts on the subjects. Here we go:
Dinah: I'll chime in in green. Roy? Roy? Where are you Roy?

1. Firstly why did each of you choose to go into psychiatry?
Clinkshrink: There were many reasons. I loved neuroanatomy and did well in it. I was a big fan of the "popular science" brain books as a med student--Andreasen's "The Broken Brain" and anything by Michael Gazzaniga. I enjoyed mysteries and "black box" kind of puzzles, and the human mind is the biggest "black box" puzzle in medicine.

Dinah: I was intrinsically interested in why people do what they do and feel how they feel. I'd planned to get a Ph.D. in psychology and do research, and then realized that if I became a psychiatrist, I'd have the option to do both research and clinical work. So why didn't ClinkShrink become a neurologist???
Clink redux: I didn't become a neurologist because gross neurological impairment wasn't interesting but mind-brain issues were. Neurologists don't deal with hallucinations and delusions, usually. There's a big difference between psychiatry and neurology.
Roy:  Please also take a look at this 2007 post, where we also addressed this question in more detail in Who Wants to be a Psychiatrist.  I grew up watching several family members develop hallucinations and behavior changes, questioning how this could happen to someone's mind.  I started out wanting to go into neuroscience research, deciding to go to medical school only to learn more about how the brain and body work together.  I later learned how much I enjoyed helping people with these problems that I decided to go into psychiatry.

2. How do you cope with some of the stupid and strange stuff people say to you? How long does it take to learn to keep a straight face?
Clinkshrink: The "strange stuff" is what psychiatrists enjoy hearing about. Complicated delusional systems can be bizarre and fascinating and I enjoy listening to that. It's not hard to keep a straight face when you know the person actually believes what's happening to them and it's frightening or bothering them. If you put yourself in their mind set and think about what it would be like if your food really WERE being poisoned, or you really did have something implanted in your teeth that controlled your mind, well, that wouldn't be very fun.

Dinah: There were a few times as a medical student when I did want to laugh. I haven't found that anyone says anything I feel is stupid. Sometimes I have have trouble empathizing with peoples' ideas, especially if they are paranoid or are offensive to me. This is unusual, though, and mostly I enjoy listening to stories about people's lives, and nothing about their pain feels stupid or strange. Some of it feels desperately sad.
Roy:  It doesn't feel like coping, it feels like trying to learn how to speak someone else's language, and understanding how they see the world differently from how I see it.

3. Do SSRI's make non-depressed people relatively happy? Do TCAs have any mood altering affect on non-depressed people as well?
Clinkshrink: Antidepressants are mood-correcting rather than mood elevating. There is some research to suggest that SSRI's may make non-depressed introverts more outgoing, and I have direct experience with non-depressed antisocial patients who like SSRI's because it makes them more apathetic and less reactive to minor slights. Dinah and Roy may have other experiences.

Dinah: Many people take SSRI's for anxiety and find them very helpful, even if they aren't depressed. I guess what Clink said. Also, they can induce mania, so theoretically, if someone with no mood disorder takes an SSRI, they could unmask bipolar disorder.

Roy:  While antidepressants can result in a flattening of affect for some (more so for SSRIs than TCAs), at least one study found that nondepressed subjects had a more positive outlook.

3. What is the neurological basis behind the symptomatology in disorders such as depression, bipolar and schizophrenia? Does it explain all the various subcategories assigned to depression and bipolar?
Clinkshrink: This one is easy. We just don't know. In spite of all the research being done in neuroimaging with PET scans and fMRI, we still don't know for sure what goes awry in these disorders, and we can't use these technologies to diagnose or subtype psychiatric diseases.

Dinah: As per Clink: We don't know.
Roy:  I spent three years doing postmortem brain research in schizophrenia.  There are quite a few replicable findings, such as reductions in markers of synaptic connections and fewer numbers of certain kinds of brain cells.  However, we don't know what they mean or how they are associated with symptoms of the disease.  Like Dinah said, we don't know for certain, but there are many good theories.

4. Why and how do some people with depression suffer from psychotic symptoms?
Clinkshrink: See answer #3. There's still a lot we don't know. Some people are genetically predisposed, some people have vascular or traumatic brain injuries that predispose them, some people have overwhelming life events that trigger an event. For me a better question is what makes people so resilient---able to survive horrible childhoods or natural disasters and "bounce back", while others can't handle routine life events without checking in to a hospital.

Dinah: Regarding the question: Great question. We don't know.
Regarding Clink's answer: I agree that their are some amazingly resilient peeps out there. I don't, however, know of people who end up in the hospital because of inability to handle "routine life events." Seems to me that people have episodes of illness....sometimes they identify a precipitant, often they don't, and sometimes I think the search for a triggering event is just a human nature way of trying to explain what may, at this point, be the unexplainable.
Clink redux: Some of my patients with severe ASPD seek admission to hospitals for, by their own report, being "unable to handle life". In other words, having no place to live, no friends or family to help them, and not being able to keep a job. They lack the resilience and ability to maintain the basic necessities of life. Or a girlfriend breaks up with them and they end up in the hospital.

5. What are your views on prevention for psych related problems? How do you think they should fit in a model of public health?
Clinkshrink: This is the next phase of psychiatry---primary prevention. We already have national depression screening day in October, and primary care providers are starting to use simple screening instruments for various psych disorders. All of this is well and good, but it means nothing if everyone can't afford a doctor. Finding the problem is one thing, doing something to solve it is even better.

Dinah: Prevention? We're a long way from knowing how to prevent mental illness. World peace and drug prevention would go a long way towards helping some people to not develop problems.
Roy:  Prevention is the holy grail.  (Insert Monty Python quote here.)

So those are my answers to lots of questions.
And mine, too!


Anonymous said...

Regarding Dinah's comment about SSRIs unmasking bipolar disorder, many people who had not history of the disorder prior to taking the drugs end up having manic reactions as a side effect. As a result, they get falsely labeled and put on heavy duty meds and are at greater risk for dangerous side effects.


Anonymous said...

Sorry, a few more things

As an introvert, I wanted to remind folks that introversion is not a psychiatric disorder.

I am concerned that with all the publicity about SSRIS making people less introverted, that people would have that impression.

Also, it seems that many mental health professionals are not doing their part in making this clear.

Anonymous said...

Agreed re SSRIs and bipolar disorder - SSRIs made me manic, but prior to that I had no bipolar symptoms, nor have I had any since. Just plain old major depression.

Paperdoll said...

Great post. Really enjoyed this one thanks :)

Anonymous said...

Wow! Thanks for the responses :-)

Although I think they have just led me to think of MORE questions! (Don't worry, I think I'll venture into the library for a neuro/psych text instead of troubling you a few thousand more.)

I love the world peace solution, I could be cynical and say that if that is what is required for prevention, then at least you know you will always have a job!

Thanks again for the responses. And keep up with the podcasts, I need something entertaining to listen to at work!


onelongjourney said...

Interesting post. I was never that interested in psych in med school. Now that I'm in therapy myself and working through some things, I think it would be interesting to go back and take some classes. Neuroscience/psychology.

Not sure at my ripe old age of 50 that I will do it, but it is intriguing.

Sunny CA said...

SSRI: I agree with those who think a drug reaction that causes hallucinations should not be considered symptom of a hidden disease. Would all those folks who took acid in the 70's be BP, then?

onelongjourney: I started a teaching credential program at age 57 and got the credential at age 58. While doing that I studied to refresh my knowledge of Chemistry, Biology, Earth Science, passing exams to teach all these for grades 6-12. Now 59 I am learning math which is brand new to me to take an exam July 10 (2nd of 2 exams) so I can add math to me credential. You are NOT too old to learn, and learning will make you feel younger in my opinion.

Kathy said...

Very interesting questions and answers. Regarding the general lack of neurological clues to aid diagnosis, there is some interesting research being done by a couple of workers at Monash University here in Australia. They are finding that signals from the vestibular system (the balance centre of the brain) show changes when the patient is suffering mental illness. The changes revert to a normal pattern when the patient's symptoms improve. I found this fascinating considering how long it can take to diagnose illness and find the right treatments. They introduced their work to the public on the following show:

Perhaps there are other bright sparks out there who can find a link between physical brain properties and mental illness so that diagnosis/treatment becomes more "scientific"!

Anonymous said...

I have been admitted to hospital perhaps 4 or 5 times in 4 decades. One could say that each of those times I was not able to handle routine life events, not because I typically cannot handle routine life events but because when I am ill, I cannot handle anything. When I am not ill, I can handle more than most people with my hands tied behind my back--career, children, teens, aging parents, physical illness, on and on.

Sarebear said...

Regarding #2, "strange stuff", I'm glad you guys have empathy for people when they believe stuff is real that isn't actually real.

I didn't know what this was like, until my second knee surgery. I had apparently a reaction between the Percocet and some of my other medication(s), and it caused a drastic slowing in my cognition, my thinking became as slow as molasses, and as the first week at home progressed, I began to have things that weren't real, thoughts that weren't real, be believed as if they were real things. Then, towards the end of the first week home, I started to have hallucinations of a sort, even.

But an example of the sorts of thoughts that would come into my head, that I would assume were real things, that it would take me some time to realize weren't, were things like, say I was trying to figure out the dosing for my next medications I needed to take in a while, I had a thought come into my head that (we had watched a marathon from cable in the month previous to my surgery, of Planet of the Apes Movies, from the 70's) I was figuring out the doses of the medications for the characters Cornelius and Zira, from the movies. They were real, and I needed to figure out how much of the medications they needed to take.

It took me about ten minutes of this floating around my head before I startled and realized, "Ohmygosh, this thought is DEFINITELY not real, and is SO FAR from reality, what the HELL IS WRONG WITH ME?!!??" In fact, I think it might have been the very first unreal thought that I remember identifying, which is why it sticks in my thoughts . . . . .

The pattern continued, every now and then I'd have some thought that I'd assume was real and a while later I'd startle, and realize it wasn't. And freak out a little, wondering what was wrong with me, psychologically, wondering if I was slowly going crazy!

See, the first week home from surgery it took almost ALL my conscious time to figure out when and how much to take my medications, my thinking was SO slow. I couldn't do much of anything else. It was very frustrating.

Anyway. And then, to have the fear of going crazy on top of it, not knowing to report it to my surgical doctors, I called and reported it to my psychologist, worried that the stress of the surgery was making me go crazy.

Eventually I called him before the 3 week appt with the surgeon, to get over the fear of bringing up these "crazy" symptoms with the surgeon, and the psychologist thought, as did the surgeon confirmed at the appt, that it was a medication reaction, not that such things are for a psychologist to diagnose, but he WAS trying to calm me down a bit.

I was pretty scared. I mean, who thinks talking monkeys are real, anyway? Besides, I was having a hard enough time figuring out my OWN doses, let alone meds for talking monkeys, heh heh heh (yes, I do have a wicked sense of humor, even now I can laugh about something that scared me, JUST a little bit.)

Sarebear said...

The funny thing is, I continued on the same meds and the symptoms went away at a week; I had sort of "shook myself out of" this trance-like thing, kind of decided that, ohmygosh, a week has gone by and I haven't been doing the exercises to recover from surgery, although I HAD managed to squeeze in, between trying to figure out med doses, the leg machine . . . . I realized, I'VE GOT to get ON with my recovery, I've GOT to WAKE UP somehow . . .

So I sort of got myself out of whatever it was, so I am still not 100% convinced it was a medication reaction, since I continued on the meds, and since I'd been almost terrified to DEATH of doing the surgery (ie, I'd almost committed suicide over it, and another issue, several weeks before). So I had wondered if my psychological state about the surgery had led to the problem, instead of meds, but we'll never know, I guess.

I'm not sure why I'm arguing this point because it would mean that I "HAD gone a little 'crazy' for a week" sort of, instead of it being "just the meds", but . . . the way it ended, and the fact I was still on the same meds, and all the stresses going into it, and the fact that it didn't start until I was HOME, when I'd started the Percocet on the 2nd day in the hospital because the lortabs that were sufficient for the first surgery were still allowing level 5 and 6 pain . . . . . . I stayed in the hospital 3 days this time too, instead of the 2 days of the first one, since I hurt more this time.

No wierdness started until after I was home. I dunno. It's just an I wonder if, now.

Sarebear said...

I enjoyed Roy's additions, now that he's chimed in!

Anonymous said...

I have been hospitalised nine times in four years and I have never thought of going there as seeking solace from routine life events. There is just no way a mother would willingly remove herself from the first weeks and following four years of her daughter's life like that. well, not me....