Thursday, January 31, 2013

The Making of a Mind

Hello again, world! I haven't posted in about three years to the date. According to that post, I was considering many different medical specialities. Looking back, I didn't mention psychiatry! And now I am more than half way through my psychiatry internship (first year of residency) at Stanford.

Psychiatry is a medical speciality that treats illness of the mind and brain. Patients might have symptoms in the areas of mood and emotions, behavior, thinking processes, perception, sleep, or language. 

Understanding psychiatry means understanding the layers we all have. As new creatures, we start out with brains that are wired a certain way. We have certain genes, which gives us certain anatomical wiring and neurotransmitters, which, in turn,  makes us more or less likely to be depressed or anxious or even have hallucinations. Now take this pre-made device out of the womb and expose it to the world. The young brain is incredibly dynamic and reactive to its surroundings, and it grows and adapts. This learning results in behavior. We get older and our brain stops changing so quickly, but it continues to change throughout out our lives.  If we are lucky, we start out with a good piece of equipment, are nurtured, loved, encouraged, face just the right amount of hardship to produce growth, but not be traumatized, avoid toxic substances, and attend a stimulating school, and so on. This whole picture, with all the layering, refers to someone's mental health. 

Another way to think about it: just as some of us have bad knees, are prone to colds, or have poor eyesight, some of us started out with wiring that is slightly different. Then, just as too much running on pavement might lead to stress fracture for some people, so might psychological trauma or stress lead to depression, PTSD, or substance use.  We can often get through a cold or a sore knee on our own, and similarly, we can often get through some depression, anxiety, and even substance use on our own.  But sometimes we need a doctor. 

Another angle that I sometimes use to think about mental illness is whether or not someone can be "talked" out of an unwell state. By that I mean, will someone respond to therapy, which would indicate that he or she is able to harness and train his/her mind. This requires a certain amount of insight and ability to step outside of one's mind and examine oneself objectively. On the other hand, some patients have illnesses that may improve a little bit with therapy, but ultimately require medical intervention, and maybe even hospitalization, for treatment. These people might have severe depression, schizophrenia, or dementia. Of course this model is oversimplified, but I think it is helpful way of thinking about the components of mental illness and how they interact and overlay.

Doctors of mental illness come in two varieties: psychologists and psychiatrists. In traditional comparisons, psychologists address behavioral or learned aspects of mental health, while psychiatrists use a medical model of disease to diagnose and treat mental illness. Psychologists use various types of therapy as their main tool.  Psychiatrists receive broader training that covers some general medicine and neurology as well, but receive less depth of training in therapy and behavioral science than psychologists. The toolbox of a psychiatrist includes therapy, medications, and even procedures such as electroconvulsive therapy and magnetic stimulation. 

The psychiatrist is also trained to help other doctors determine whether a patient has a primary psychiatric disorder or whether an underlying medical condition might be responsible for psychiatric symptoms. In particular, many neurologic disorders are accompanied by or mimicked by psychiatric disorders. Patients with parkinson's disease may have hallucinations. Patients with multiple sclerosis may experience depression and decreased cognitive function. Personality change might be the first symptom of a brain tumor. Also, patients might have neurologic symptoms such as twitches or seizures that are actually psychiatric in nature. Chronic pain is another entity that can be approached from a psychiatric perspective.

So there are a few ways to understand psychiatry and a few reasons why I think it's a great field. My final thought for the night is that I love that the marker of success in psychiatry is improvement in a patient's ability to do the things that make us human-- like feel, think, and love-- and to participate in meaningful activities such as work and family life.