Psychiatry: A New Understanding
Having been interested in psychiatry for a long while, I have now embarked on several months training in the discipline. And although mental health is never far from the public eye, it seems to be that a general understanding of mental health and disease is vastly lacking. But in my fledgeling understanding, I have begun to know things just that little bit more.
Psychiatry and the Mind
To begin with, the concept of normality, whether it is physical or mental health, is debatable. When it comes to physical health problems, like chest pain, we are quick to recognise what is ‘abnormal’ and would require action, how much action and the mode of action. It is not a necessarily binary situation, but we know enough about the natural history of a disease, biology and treatments to make a workable approach.
Psychiatry, however, is less clear-cut. Although science has, for a long while now, explained mental health problems in terms of physicality, biology and chemicals, the understanding of the human aspect of the disease still warrants expert judgement. Phenomenology, that is the study of words, has attempted to categorise mental health complaints within recognisable schema; what one may describe signposting depression should be generalisable.
My sadness and your sadness should be understood in a similar way, and their approach into depression more so.
This has had some success, and within the streams of both biological and psychoanalytic models of mental health, has allowed us to recognise disease in a functional way. By understanding the language of disease, as expressed by our patients and selves, we can learn to spot patterns in the same way we may read an ECG. To an extent. However, a psychiatric disease is not as simple as an ECG*.
The issue with psychiatry, which has been long debated, is the suggestion that, including psychotic beliefs (those not grounded in reality or truly understandable by doctors,) we do not classify disease purely on biology, but on their proximity to social norms. This is quite foolhardy philosophically since all of our norms are prescriptive and based on a shared belief, which when applied to metaphysical understands of the world is rendered mute.
Put simply, we have created the goal posts by which we measure psychiatric abnormality, and unlike physical problems (if treated as separate,) there is a great discordance between people on what disease actually means. To some, their core beliefs may seem entirely rational and healthy, but to others, a clear indication of being unwell. And how do we make these judgements?
Apart from CT scans, biochemical markers and agreed diagnostic categories, we fray on the fringe of relative value.
And when you review popular media, for example blaming massacres on the mentally unwell, regardless of whether this is the truth (which it rarely is,) you can see how a moral value has been ascribed to behaviour, and how it can be used to suggest a diagnosis. You need to look no further than the ‘luny left’ and ‘liberalism is a mental disease’ to recognise this shortcoming of human understanding.
So when I meet my patients, I cannot fully assess them without realising that my diagnosis is shining a thin light on a large area, where the boundaries of normality are hazily defined. Does this mean that all psychiatry is value assessed, not necessarily, there is clear science and patterns, but we must be aware of where the evidence ends.
Evolutionary antecedents and Art.
We have known for a long time that the human brain is vastly imperfect. We also know that morality, that is our measure of the ‘goodness’ of things, is a relative concept. In fact, some philosophers such as Freidrich Nietzsche have gone as far as to claim there is no such thing as good and evil, and others have renounced all understanding and attributed such judgements to God alone.
What we do know is that behaviour is not unpredictable. We know those common traits are common because they are either useful to survival, non-affective or tied to something useful. For example, we know that running fast is useful alone, won’t tend to get you killed directly (unless you run off a cliff,) and works best with good hearing and reactions (for more on this, see co-adaptive genetics.)
Herego, mental health problems do not escape the scrutiny of evolutionary explanation, and this is where the science of anatomy, genetics, sociology, psychology, behaviour, chemistry and anthropology meet the human disciplines of art, literature, history, speech, song and expression. The human mind is a result of its best compromise and survival, and with it, mental health problems have shared a journey.
So when we interview our patients, we see the humanity of disease, etched through eons of evolutionary history, expressed in the contemporary terms of our sociocultural understandings. A psychotic belief is amoebic, and will likely include tenets of that person’s popular culture, as opposed to one of the ancient Egyptians. This cannot be avoided but can give us clues to an underlying constant process.
Psychiatric disease is likely part of our survival, for better or for worse.
The history of psychiatry and philosophy is intertwined, and before such things as brain imaging, it was the brain and its wake light pondering that allowed us to conclude the nature of things. Logic, experiment and results were used across a vast arena of disciplines, from which arose different schools of thought such as Freudian Analysis.
The later schools of medical models have all but usurped the philosophical and analytic, but the latter still play a vital role in our understanding. It is likely that with further science we may be able to pin psychiatric disease, or at least its base aetiology (ie cause,) on something purely biologic and explained through measurable variables, but until then, we rely on our interpretation of behaviour to guide us to the scan.
Diagnosis and Detention
So with the somewhat hazy and complex architecture of the interplay between evolutionary explanations of psychiatric disease, medical explanations, sociocultural norms, variable and diverse human expression and the legal system, the idea of diagnosis and treatment becomes one of great importance. And one that can cause great contention.
We can mostly all agree that someone at risk of suicide due to severe depression may need to be sectioned. We can also all agree that it is in their best interests to do so. This is because we value life, but also claim knowledge that psychiatric disease renders one incapable of deciding what’s best for themselves. At the extremes, we tend to agree, but in the middle ground, there is less commonality. We agree on death, but sadness is a different issue.
And when it comes to issues that have a socially contentious element, such as gender and health, we must listen very carefully.
I work in an acute psychiatric unit, which means the patients that I see are on the more severe end of the spectrum, that is that they very rarely occupy the middle ground of disease severity. I see patients who believe they are being monitored by government agencies (which arguably, we all are) or can see ancient ghosts wandering the halls.
My view of psychiatry is within the deep end of the human mind, the echoes of our ancient brains pushed to their limits. And as a growing student of the evolutionary explanations for psychiatric phenomena, it is becoming abundantly clear to me that a full understanding of the subjective nature of the disease is probably beyond pure science, it will be found in expression.
So how does this translate to sectioning a patient, or indeed, deciding if and when someone should or will be treated? To give a general answer to this is difficult, but I will give it a try, based on when the patients own subjective view of the quality of their life is jeopardised by their disease.
But for those actively psychotic, i.e who have left reality behind, such subjectivity is lost, and we must use our own sociocultural norms and understanding of reality to make sense of their experience. And we do our best. Sometimes that means bringing people in against their will, and believe me, that is rarely an easy decision.
Treatment and Life
So having trawled, on a surface level, some of the complex themes that goo into diagnosing and deciding to treat a psychiatric illness, what of treatment? From my experience, the variety of methods out there provides hope. Whether it be medication (which addresses biological and chemical causes of disease,) ECT (which, as far as we know, derives its role in chemical and anatomical methods,) and therapy, which helps us to understand and correct aberrant thinking, we do see changes.
Sometimes these changes are drastic. I note one man who came in severely depressed, paranoid, almost catatonic, who after a few weeks of ECT is now back to shopping with his wife. His subjective view of the world and his disease has changed drastically as if some great mist has disappeared. Others are less pronounced, where a persistent delusional belief is still present, but less concerning.
In each case, our measure of success is built through understanding the subjective view of our patients, either phenomenologically through an interview, or objectively through an analysis of behaviour and biochemical changes. This is a far cry from the newspaper headlines and personal accounts that litter the blogosphere, but good is being done. Psychiatry, a discipline of the old and new, saves lives.
Placed in context, however, we must always remember that our view of success is based, at least in part, on prescriptive sociocultural norms, derived through evolutionary behaviours and limited by our own bias and cultural beliefs. The solution to the malady of psychiatric disease is one that may never be fully answered, but until then I find myself in a world where I can make a difference.
So far this has been an enlightening journey. But to be a good psychiatrist means truly understanding your patients, their views, expectations and dreams based upon their understanding of a world that we may not agree on. We must be prepared to listen more than talk, read more than present, understand that we know little. Crucially, we must know ourselves to know our patients.
It means understanding history, evolution, biology, neuroscience, art, writing, speech, religion, social causes and much more. It is by no means simple. I hope to be starting to get to grips, but I can always improve.
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*Note, the interpretation of an ECG is far from simple. However, in relative scales, the number of clear diagnostic changes available comparing ECG to phenomenology is vastly disproportionate. This is an academic and rather histrionic comparision, so apologies to the Cardio Reg.