Category Archives: Psychiatry

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.

 

 

 

 

Search Engine Data May Help Diagnose Depression Earlier

A new study published in JMIR Mental Health has revealed that searches relating to Depression and its treatment spike at different times of the day. The data shows that searches around depression peak between 11pm and 4am daily, showing a clear focus overnight. The reason for this isn’t immediately clear but may tell us more about the day to day lives of patients. With depression a growing problem, these insights may help us to recognize depression earlier. And, with that, to help people access treatment.

Depression and Diurnal Variation.

It is common knowledge that the symptoms of depression vary in severity over the day. The classical picture of waking up ‘sad’ and ‘feeling better’ later is one of just many. But little has been done to actually quantify this in real terms over a large population. The researchers reviewed search data of key terms around ‘depression’ to elucidate a pattern. They found four peaks between 11pm and 4am, and relative ‘troughs’ between 5am and 10pm. Essentially, people were trying to learn more about depression and take ‘online tests’ during the night.

depression data diurnal medicine

Depression is a common and difficult problem. Data may help earlier diagnosis and treatment. Flickr.

It’s hard to directly claim what this may mean without considering multiple factors. The first is the simple issue of time availability, with daily work commitments limiting free time to search. The second is that more people are likely to sit on computers overnight, increasing the likelihood of searching for anything.  However, the team’s statistical analysis shows a clear difference between searches at different times, suggesting something significant. What this may mean in actuality will require further study. But it could be very useful information indeed.

Why May People Search For Depression At Night?

Aside from the reasons discussed above, it may be that this pattern is well explained by what we already know. Depression is known to be associated with anxiety and sleep disturbance. We also know that with depression, in many cases people feel better later in the day. It is very possible, with a number of assumptions, that the combination of these two factors may explain the findings. If people feel more energized later in the day and overnight, and cannot sleep due to their symptoms, there would be peaks in activity. The data would seem to support this idea.

depression sleep diurnal data diagnosis

Depression is associated with sleep problems. Flickr.

However, further research is needed to compare these findings with the actual patients themselves. It would not be fair to assume without more supporting evidence. The data itself does not reveal whether those looking for ‘depression’ related information were actually suffering from depression, suspicious of being depressed, or simply interested in the condition. There is a lot of conjecture. But what the study does provide is strong evidence that people are more active in learning about depression at night.

Given what we know about depression, this may provide a new way of recognizing depression in the undiagnosed, and helping to monitor treatment success in patients.

A New Way Forward

Depression is a growing problem and early intervention is key in its treatment. This new data shines light on the daily lives of patients and the undiagnosed. It may be that recognizing the patterns tells us not only more about the nature of depression but could provide an early warning system for those at risk. But how this may work in practice is another question altogether. The first step may be interviews with those concerned, establishing the nature of their condition. Only then could a suggestion be made that ‘search engine’ data be instrumental in earlier diagnosis.

So what do you think? Could search engine data help doctors diagnose depression earlier? Are you concerned about privacy? Is there a happy medium between? Let us know in the comments.

What’s Next?

  • Learn more about Depression and why early diagnosis is best.
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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. If you are concerned about your health please see your local healthcare provider. Sources available within main text via hyperlinks. If you find new information that contradicts this article, or feel that an error has been made, please do let me know via benjanaway@outlook.com. I will be happy to hear from you. 

 

 

Why Do We Worry So Much? Turns Out, Its Nature Falling Behind. Inside; The Science Of Anxiety.

There are times when I feel that the world is exploding around me. My heart is racing, hands shaking and breath hard to catch. Often there is no clear reason for these symptoms, or the panic that rushes through my brain. Other times I find myself unable to sleep, and as I watch the hours pass in the twilight hours I wonder why I feel like this. But the answer is something common to us all, Anxiety.

“To venture causes anxiety, but not to venture is to lose one’s self…. And to venture in the highest is precisely to be conscious of one’s self.” Soren Kierkegaard

So what is Anxiety, what does it feel like and how can we live with it? I teamed up with Metro journalist and Mental Health Advocate Hattie Gladwell to get to the bottom of it.

What is Anxiety?

Anxiety is a term used to describe the symptoms of a number of ”Mental Health” conditions ranging from ‘Generalised Anxiety Disorder‘ through to specific phobias. These can include agoraphobia (fear of being out of a safe place.) It can also include such things as ‘Panic Attacks’ and be linked to conditions such as Obsessive Compulsive Disorder.

Really it represents a whole spectrum of conditions where the world can be uncomfortable to the point of disease. The official definition given by the ICD-10 (a national registry of disease,) reads like this;

‘A category of psychiatric disorders which are characterised by anxious feelings or fear often accompanied by physical conditions associated with anxiety’

A rather less than elucidating definition. But what does Anxiety actually feel like?

What does Anxiety feel like?

“I am exhausted from trying to be stronger than I feel.” -Unknown (source: paintedteacup.com)

Dr Google will tell  you many symptoms, but it seems that the experience of anxiety is very individual. At the centre of it is worry, which can be accompanied by physical symptoms. These symptoms, if clustered together, can present a ‘syndrome’, which can lead to a specific diagnosis. This is all rather complex, and without seeing a doctor, self-diagnosis is dangerous. But we aren’t here to talk about specific types, but what it can feel like to live with it.

‘I have health anxiety, its all or nothing. I will get a surge in adrenaline, hot and cold flushes, shaking.  It happens more when I’m isolated and have more time to think about it. Most days I am panicking that my whole life will be put at hold.’

For me the experience is not entirely different. As a patient of depression, I consider anxiety (a well recognised association of depression,) as an uneasy partner. For me the problems started young, fear of making a fool of myself in front of friends, or fear of being disliked. Over time this changed, and my concerns became focussed on relative fame, (if you could call my experience that,) of being judged by others for my words and opinions.

I promise you nothing is as chaotic as it seems. Nothing is worth diminishing your health. Nothing is worth poisoning yourself into stress, anxiety, and fear’  – Steve Maraboli

This may seem silly to some, but I have had panic attacks after tweeting. I have stayed up for hours refreshing a timeline, worrying what others may say. These feelings have become more general, to a point where a phone call from an unrecognised number begins a spiral. Its uncomfortable, draining and often completely unnecessary, For me anxiety is a terrible affliction that seems bizarre later.

Living with Anxiety

If you suffer from unhelpful feelings of anxiety or catastrophic thinking, your Chimp is in control. – Dr Steve Peters, Psychiatrist 

Anxiety, for many, is a lifelong problem. Depression has its ‘Black Dog’ (mine is named, and I have grown kind to it,) but Anxiety may need a different animal. You can pick yours, but mine can be a Vulture. Treatment is difficult, but there is great success in Cognitive Behavioural Therapy  and medication. These treatments recognise the problem as a system of thought, action, reaction and behaviour.

By identifying your own, and making adaptions, you can begin to recognise when you are being taken over and do something about it. In his best selling book ‘The Chimp Paradox‘, Psychiatrist Steve Peters describes these feelings as being hijacked by ‘The Chimp’, an analogy for the emotional centre of the brain.  By recognising this, and through several techniques, Peters believes that you can take back control.

It is a great book, so give it a read.

Interestingly, these ideas are not new. In fact, Neuroscientist Sam Harris has discussed the overlap between neurocircuitry, religion and spirituality at length in his book ‘Waking Up.’ It is a big subject, but it may be that ancient religions, such as Buddhism, have already figured out how to deal with the pressures of the world by reconsidering their significance.

‘I am undergoing CBT, which I am finding very helpful. I use apps, but they aren’t a cure, but can be short term relief. They help me calm down. I tell myself that although things are horrible right now, it will pass’ – Hattie 

So if you are like me, there is hope.

If you enjoyed this article and would like to discuss it, or pitch ideas for follow ups, follow me on twitter or email me at benjanaway@outlook.com. I am happy for this work to be reposted, just let me know if you do!

What’s Next?

The views above are those of Dr Janaway alone and do not necessarily represent those of his affiliates. They should not be taken as medical advice. If you are concerned about your health please access your local health provider. Please feel free to follow Dr Janaway on twitter. Image courtesy of Pixabay.