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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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The opinions expressed in this article are those of Dr Janaway alone and may not represent those of his affiliates. Featured image coutersy of Flickr.

*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.

 

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‘Increasing prevalance’ of PTSD in UK Veterans after recent conflicts.

New results published in the British Journal of Psychiatry suggest that post-traumatic stress disorder (PTSD) may be on the rise in service personnel. The condition, associated with exposure to trauma, has long been long linked with combat. But this new study highlights just how much Veterans may be at a higher risk than active soldiers.

But to really show what this means, I also talked to a veteran, who was kind enough to explain what PTSD feels like beyond the data.

I knew that something was different after my six-month tour of Afghanistan. It was really difficult to go from an environment where I fighting in close quarters with the enemy on nearly a daily basis, to an extended Christmas break with my family in a quiet suburb. At new year we had guests and I didn’t even go downstairs to see them. It was tough interacting with people who had no idea what I had gone through. I just couldn’t understand why people would get so angry over the little things or first-world problems; I still don’t today. – Soldier X

Worse mental health outcomes

A cohort study compared over 8000 personnel either deployed to Afghanistan and/or Iraq, with those active but not deployed, and those newly active since 2009.  The study reviewed the participants in three phases, collecting data on mental health symptoms and level of alcohol use during the study period.

The first phase examined soldiers deployed to Iraq, then the second followed these up and added those deployed to further conflict, and a third to new soldiers as well as those already under review.

The study found that, overall, 21% of those reviewed displayed symptoms of common mental health disorders (such as depression,) and that those who had been deployed to the conflict were at a higher risk. 6.1% of those surveyed showed signs of probable PTSD, with a significantly higher risk in those who had seen active duty.

I was in a close-combat role for six months, which was really intensive both physically and mentally. I was also responsible for the lives of 28 soldiers and I had to make tough decisions daily; which at the time was a lot of pressure for a 25-year old. I know the decision-making really affected me because its something I still think about a lot and often run the scenarios through my head with “what ifs”.  – Soldier X

All in all, the overall risk was 9% for veterans and 5% for those still serving, and higher in combat roles and support roles such as logistics and medical personnel. However, the study also showed that alcohol abuse rates have dropped during the same time period.

Post Traumatic Stress Disorder

PTSD is a mental health condition characterised by the emergence of unsettling or traumatic symptoms from short months to years after a severely troubling event. Those who develop the condition may report a combination of symptoms, either ‘reliving’ the event in some way such as through flashbacks or nightmares, or through ‘numbing’ by avoiding emotional subjects or addressing their symptoms.

It took me nearly three years to talk to someone about it and get some help. I still don’t talk to my partner or family about it; I find it easier to talk to professionals or put it in writing. The hardest part about asking for help was that I didn’t think I needed or deserved it, there were plenty of other soldiers that I knew of who had been through far worse experiences and were not seeking help – so why should I?  – Soldier X

The link with military work has been long known and likely due to the intense and terrifying experiences. And the legacy is one that is unfortunately predictable. But this new study sheds light on how PTSD may develop, not as something that primarily affects soldiers, but preferentially affects those who have survived and come home.

It may very much be that the evolutionary antecedents to our survival, forged long ago in the heat of prey vs predator, have become maladaptive. Or indeed, never had the chance to become adaptive over time. Repeated exposure to life and limb trauma is not a natural state which can be readily traced back beyond tribal warfare, as survival was much less guaranteed.

Perhaps a study like this, which highlights the true cost of war to the victor, can help us learn that suffering is ubiquitous in theme, just different in nature.

PTSD is always going to happen in war. There will always be traumatic events, but I think we could deal with them a lot better. Mental health became the elephant in the room in my Battalion, with some soldiers suffering from horrific cases of PTSD. One of the reasons it took me so long to talk about it was because it took 13 months to see a mental health professional after I requested it. – Soldier X

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The opinions expressed in this article are those of Dr Janaway alone and may not represent those of his affiliates. Featured image courtesy of Flickr. Full informed consent was gained for interview and distribution of content obtained during the interview. All profits from this article will go to the Poppy Appeal.

 

 

 

 

New research suggests that we remember life like a film

A new study has shed light on just how the brain may process life.  We have known for a long time where memories may be stored, but new research gives us a tantalising glimpse at just how this happens. Publishing in the Journal of Neuroscience, researchers may have just shown us just how ‘Hollywood’ are memories may be.

Built for complexity

The new data, gleaned from hundreds of participants, suggests that the hippocampus (an area of the brain associated with memory,) is able to split information into manageable chunks.

Participants watched films (including Forrest Gump,) whilst hooked up to a functional MRI (which can map brain activation in real-time.) At the same time, 16 observers watched the same film and indicated when they believed that ‘events’ in the film began and ended.

Strikingly, it seemed that the brain was most active at these ‘event points’, suggesting that the entire film was memorised in small sections as opposed to one flowing narrative. All in all, it suggests that our brains process information into workable bits of information, much like a film reel.

Brain built for simplicity

So what does this add to our knowledge? Many theories already suggest that the brain acts as a filter for information, only storing what is important. If we were to take in every small bit of data, we would likely be overwhelmed. This new study shows us that the brain may do this based not just on space, but also the emotive and narrative component of what we see.

It may very much be that memory, like a good film, depends on important and emotive set pieces, with the most important moments given the most weight. And when we already know just how tricky memory can be, we can now ask why the brain chooses as it does.

So what do you think? Is there a reason the brain may work like this? What are the benefits? Let us know in the comments, and if you enjoyed this article please share!

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Wedding Crashers

The opinions expressed in this article are those of Dr Janaway alone and may not represent those of his affiliates. Featured image courtesy of Flickr.

 

On Dying. A Message From Scientific Thinking.

Having spent several years of my life dealing on the frontline of death, it is no shock that the very nature of the end is one that I have often considered. As an atheist, the very idea carries perhaps more weight than for those lucky enough to hold beliefs in a second and eternal life.

But regardless of introspective journies, or indeed the hard moments where I have lost patients and family, there is some universality to the finale.

Beyond the Curtain

To consider the nature of death, one may begin with what we consider life. And although neurobiology may teach us many lessons about the beginnings of what we consider ‘consciousness’, it is clear that there is a difference between the passive actions of molecular machinery and the purposeful meanderings of creatures such as we.



DNA, the very building blocks of species innumerable and immemorable, has no memory beyond its structure, which within itself is only transient and ‘dies’ at the impromptu whim of little force. You would not call it alive in any real sense, any more than the bark of a tree or the ebb of a river. Motion does not mean life, only motion.

The next step up, the interaction between chains of organic molecules guided by chemical gates and gradients, is just as robotic and carries with it no semblance of intelligence. It is us that have defined agency in the evolutionarily derived actions of physics and chemistry. Once again you would not ask a melting lump of sugar how it feels.

So to jump to a creature that we consider alive we must allow for something different, the ability for an organism to not only respond to something outside of itself, (like simple molecules will,) but to manage its response over time.

It is within the structure of a third order neuron system that we begin to see feedback loops that form the basis of sentience, that is the binary form of what, as humans, we owe our special experience to. It is the macrocosmic version of these loops, interacting at incredible speeds, that give us the illusion of what we call ‘mind’

And regardless of our supposed consciousness, which until recently many believed signified some transcendental soul, we can reduce not just our minds, but our entire existence, free will included, to the non-sentient interactions of molecules carved into man-shape.

Considering this, the idea of death becomes one of both greater significance, and lesser all at once.

Before the Gates

So assuming that Science can provide explanations of how we have come to be, think and live, it is fair to demand that it provide an explanation for death. The biological model of death is quite simple; the cessation of an organism in all forms of modality except physical, which itself eventually passes with the sands of entropy. There is no room for a soul, which ceases as the machinery of the body grinds to a halt.

Whatever consciousness, thoughts or soul that once was disappears, a temporary illusion of apparent sentience maintained by the limited capacities of our brains, tempered and reminded of its presence by our nervous systems, intrinsically tied to the physical form in which it carries out it’s life. Simply put, the ‘soul’ is nothing more than a function of the soulless.

But as thinking creatures, who have achieved so much as to fly jets and write poetry, the very concept of death, beyond a question mark or ancient book, eludes us.

To ask what lies beyond, how it may ‘feel’ and what it ‘means’ is a question that Science itself has not answered beyond the retrospective analysis of those who have experienced near-death experiences. And even then, the ‘white light’ and ‘feelings of warmth’ so often attributed to a deity can be explained the death secretions of the brain in the form of DMT and other chemicals. Once again, we have applied agency and purpose to the banal.

To consider the true feeling of ‘non-being’ is simply beyond us. It is like asking what life felt like before you were born. I have no memory of the 13 or so billion years prior to my birth and will have no experience of the trillions after my death.

The experience, unless I am dramatically wrong in my atheism, will be very much the same; beyond comprehension, as there is no mechanism by which we may comprehend it. We are asking a rock to know itself.

As for purpose of life and death, there is likely none beyond which we choose. And if free will is an illusion, which many believe it to be, then the choice itself is mute. The purpose of life is simply existence but without agency or overriding design.

Freidrich Nietzsche may have come the closest in his estimations, in that purpose cannot be known as the universe itself is unknowable, and although science has taught us much about the universe, it has only shown us what and how, not ‘why.’

After the Fall.

To some, the idea of death is one of immense tribulation. I would agree myself, and no wager as simple as Pascal’s, or approach as defensive as agnosticism, changes that. The realisation of the mechanical nature of the human body and the illusory spirit is one that could, if we so let it, steal our significance in both the personal and cosmic sense. Such intellectual discussion means little to the lady dying of cancer, or the old man of kidney failure.

Such arbitrary ruminations are the gift of a far-off death, the distance of time or reality, the time to muse. But upon approaching it, either in hours, days or weeks, the intellectual arguments may provide no solace. In this sense, I very much understand why so much of the world holds on to the safety of heaven, because the reality of randomness and pointless may make life seem unfair.

Why live without purpose, why die at all?

However, even the most logical deductions about the nature of death and it’s purpose can reveal something truly astounding. And that is that if the universe is without agency or purpose, and we are nothing but illusory consciousness formed of asentient molecules, then our lives are incredibly worthwhile.

In the vast cosmos, we have sprung to life, and death is not some great messenger or test of faith, but simply the end of that cycle.

Death is neither bad nor good beyond human morality, but a cessation. The molecules in our bodies will not feel the end, or eulogise the passing of a ribosome. But those we leave behind will greave the loss of kin, another one so unlikely to have experienced life.

For me, as cynical as I am, there is a great beauty around the end of things. It teaches us, perhaps not all at once, that the true value of life is in its living.

We don’t require purpose, just the ability to define it. We don’t need free will, just the illusion of agency. We don’t need an eternal life, just the moments that make us forget about the inanity of it all.

And being a doctor and an atheist, death has taught me this; the end is common, constant and beyond knowledge, but a good life is not. So enjoy every moment, keep writing poems, keep flying jets, keep asking questions and, for as long as you can, breathe.

 

Image courtesy of Flickr.

 

 

 

Glimmer.

biology mental health

Here? Perhaps?

That links to something, it shines, but wait, no.

That was nothing.

Maybe here? More black. But a smile for a second.

Doze.

Breathe. The light is still on. Shapes, it’s okay. Find more.

But, it’s not there. Something outlined, but, turned away.

Circles. Audio. Snippet. Snipped it.

Reasons.

Broken bridges.

Warmth, soft. Hard. Cold, warm. Switch.

Books. So many books. Marked pages.

Maybe here?

Doze

Doze.

Well I keep searching for a heart to love.

Smile. Coffee. Smoke.

Doze.

Maybe here.

Breath.

But.

 

 

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