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!