When I browse the net, or listen to people, I find that many think Psychiatry is about Freudian theories, ‘chemical imbalance’ and dangerous medicines that turn patients into zombies. This post is for anyone who might want to know how psychiatrists deal with mental illness.
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People sometimes tell me they don’t believe in mental illness.
I think that’s a reasonable belief to hold if one has never had a brush with it, never known anyone with a mental illness, nor heard of people like John Nash.
As a psychiatrist, I view mental illness like any other medical problem. But this is only the starting point of the treatment algorithm.
An orthopaedic surgeon fixes a broken humerus, depending on
- the position and type of fracture,
- the degree of displacement of the fragments, and
- the intrinsic stability of the fracture.
To treat a patient with a disruptive break in the normal tenor of his life I look at the same parameters as the orthopaedic surgeon, viz.
- position and type of break, i.e. whether it is psychotic, depressive, anxiety-related, relationship-related, etc.,
- degree of displacement, i.e. how much it has thrown his life out of whack, and
- intrinsic stability of his psyche, i.e. what are his strengths and what support he needs.
And these are the things I may do:
- prescribe medication, or admit him for in-patient treatment,
- help him keep his life together, like the plates, screws and cast that keep the broken ends of a bone in contact, until he’s able to cope (supportive psychotherapy) ,
- help him learn how to protect what was broken and re-set, the way an orthopedic surgeon might suggest a safe sleeping position with a fractured collar bone (cognitive therapy).
But, of course, this is not all there is to it.
The International Classification of Diseases, or ICD-10, defines a mental disorder as ‘a clinically recognisable set of symptoms or behaviours associated in most cases with distress and with interference with personal functions.’
The American Psychiatric Association makes it simpler, saying ‘mental illnesses are health conditions involving changes in thinking, emotion or behaviour (or a combination of these). Mental illnesses are associated with distress and/or problems functioning in social, work or family activities.’
These bland definitions don’t reflect how devastating mental illness is.
- It is not just thinking, emotion and behaviour, but the patient’s integrity as a human being that is at stake: he cannot control his mind, the very essence of who he is.
- And it is not merely problems functioning in social, work or family activities, he can’t even understand what’s going on within him. It is distress with a capital D.
People are confused about whom to go to for anything that bothers their minds. This lack of clarity is because the roles of psychiatrists, psychologists and others who try to help the mentally troubled have been blurred in recent years by an overload of information about ‘mental health’ in the media.
As a psychiatrist I treat mental illnesses with medication and psychotherapy. Though the earliest psychiatric medicines were serendipitously discovered, specific medicines have been introduced through research since the 1950s. They work. I have seen them work.
Used judiciously, medicines are very effective. To appreciate their value one only has to remember what happened to the mentally ill before the 1950s. Patients don’t come back every month to pay me a social visit; they come back for review and prescriptions because they can see the difference, after the hell they and their families have been through before taking medicines.
I discuss both therapeutic effects and short- and long-term side effects with my patients, and they are willing to take their chances. There is a great deal we don’t know about the workings of the mind, but I explain in simple terms what might be happening in their brains. If nothing else, this allays the guilt that they somehow caused their own mental illness. Some of them are relieved that medicines exist because they’ve come with the expectation of ‘electric shock treatment’, thanks to movies!
The much-maligned term ‘chemical imbalance’ is just shorthand for reassuring patients that maybe a small brain process is affected – or ‘balance’ if you will – and they don’t have lesions like tumours in their heads, as some think. I use this term only when patients request CT scans of their heads to see what is wrong with their brains, or ECGs to figure out why they get palpitations during panic attacks. I need to convey that they can’t see it, any more than diabetics can see the defect in their pancreas on a scan.
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So, what are mental ilnesses?
The DSM-5 (Diagnostic and Statistical Manual, 5th edition) and the ICD are the two classificatory systems in use. I will highlight mental illnesses most commonly seen in practice and, just for convenience, follow the order in which they appear in the DSM-5.
I hope this helps.
The DSM-5 starts with the category of Neurodevelopmental Disorders.
When brain and nervous system development are disturbed during foetal life children can manifest any of these problems:
- intellectual disabilities
- inattentiveness and hyperactivity
- problems recognising letters and numbers as in specific learning disorders
- odd behaviour as in autism spectrum disorders
- problems in physical coordination
There are special centres that care for children with these disorders. Keeping them on our radar is important because ongoing research has definitively shown that they have a biological basis, which means they may be preventable some day.
Of these, children with Attention Deficit Hyperactivity Disorder do well with medication. A detailed history from parents, a clear description from the class teacher, and my observation of the child over the 30-40 mins I spend with him and his parents are carefully weighed before reaching this diagnosis. No child should be given a medication unless it is fully justified.
Most children with mild ADHD settle down without medications by the time they are eight or nine years old. So I prescribe medication only if the ADHD is moderate-severe, which is a clinical judgment. Almost every child I have prescribed medications for has shown a marked and sustained improvement with medication. There are known side effects that I minimise by using lowest possible doses and allowing drug holidays. The diagnostic validity of ADHD is constantly being questioned, and many people call them ‘indigo kids’ and have them home-schooled. I understand that sentiment too.
The DSM-5 then moves on to Schizophrenia spectrum and other psychotic disorders.
These illnesses affect about 1% of the human population and are characterised by delusions, hallucinations and disorganised speech and behaviour. However, before making a diagnosis, it is important to rule out brain pathology like a tumour, infection, or the use of street drugs that present with similar symptoms.
An example: Some time ago, a middle-aged man was brought to me with complaints of sudden change in behaviour, uncharacteristic violence and incoherent speech. History and physical examination led me to a provisional diagnosis of meningitis, possibly tuberculous. I immediately had him seen by a physician, who concurred. The diagnosis was confirmed by lab and radiology, and treatment started.
Once schizophrenia is diagnosed, antipsychotic medicines are given and the patient returns to nearly normal in a few days. Medicines need to be continued and they improve quality of life in the long term. Of course, there are side effects, but they get better with time.
The only really terrible, irreversible side effect of some antipsychotics is Tardive Dyskinesia – jerky movements – that can develop in patients who have been taking antipsychotics for a long time. Reports regarding its prevalence vary widely and there are no approved treatment methods, except to switch to a drug that is less likely to cause TD. This is a highly unsatisfactory state of affairs that has no solution at present. Of the hundreds of patients I have prescribed antipsychotics for over the years I have seen only two cases of TD. I cannot predict who will develop TD any more than someone can predict who will develop leukaemia, nor can I withhold antipsychotics within the medical framework of treatment.
The third part of treatment is counselling family members. This includes explaining the illness, answering their questions, and giving them guidelines for keeping him stable. Often family members are under tremendous stress and need support too.
The next category in the DSM-5 is Bipolar and related disorders.
Bipolar Disorder is common, affecting about 2.5% of the population worldwide. Wild, uncontrollable variations in mood, or mood swings, are a distinctive feature of Bipolar Disorder.
Medicines control mood swings quite well. They are far from perfect, but patients are grateful they work as well as they do. They are glad they don’t have to get up in the morning dreading what mood they may get sucked into that day. They don’t live in fear of breaking down and howling for no discernible reason, or going into a ‘high’ and doing something regrettable. Medicines do give them the stability to live and work as they wish. But none of them will take to the internet to write an ode to Lamotrigine or Lithium, which is probably why one only comes across diatribes against psychiatric medicines on the net.
Mood disorders sometimes present with high-risk behaviours like attempting to jump off the top of a multi-storied building with the happy conviction that one can fly, or suicidal attempts due to deep depression. These are treated as emergencies. The patient is out of touch with reality and has to be protected. A brief history is obtained from the attendant and the patient is sedated. A detailed history and relevant investigations to rule out epilepsy, endocrine disorders, brain tumours or substance abuse must follow.
When the patient is stable he needs counselling to understand his illness. His family has to be taught to recognise behaviours that presage a relapse. The family often needs emotional support too. All of these are the responsibility of the treating psychiatrist.
The next category is Depressive Disorders.
I view depression more as a symptom than a diagnosis. Just as ‘fever’ and ‘headache’ cannot be diagnoses, depression points to an underlying medical or psychological problem.
When a depressive episode has lasted longer than two weeks it is called Major Depressive Disorder. In some cases there are obvious triggers. In others the low mood seems to just come out of the blue. In some, long-suppressed anxiety may have led to depression. Depressive episodes can usually be dealt with by medicines/counselling, though some patients require long-term psychotherapy. A lot of what is labelled ‘depression’ by people are just the normal vicissitudes of life, and temporary. Everyone needs a patient ear and a shoulder to lean on at some time in their lives, and with the dissolution of the joint family system, outside help may be needed.
That brings me to something I have been confronted with several times over the years. Patients, especially smart and sensitive young people, telling me they are depressed because life is pointless: study, earn, marry, have kids, buy house, buy car, go on exotic holidays, then what? Of course, the depression is real and does benefit from psychotherapy, but it is not a mental illness. Perhaps there should be consultant philosophers to answer these existential questions!
Still, it is important to be alert to symptoms and signs of physical illness. Why, even vitamin deficiencies or anaemia could present as depression!
Here is an example: A 56-year-old man with no past history of depression presented with repeated expressions of suicidal intent. His wife was in tears while he answered my questions tonelessly. From the history and examination I reached a provisional diagnosis of hypothyroidism and sent for necessary lab tests. The diagnosis was confirmed. I referred him to an endocrinologist and reassured him and his wife that it was a common problem – like diabetes – and he just needed a medicine for his thyroid problem.
Another case: A few years ago I saw a 60-year-old woman who was facing a bad life situation and had symptoms of depression. There was no past history of depression. A week later she had marked memory loss that couldn’t be explained as dementia or pseudodementia. I referred her to a neurologist and the diagnosis was Creutzfeldt-Jakob disease, a rare degenerative brain disease whose prevalence is one in a million per year. She passed away in six months, life expectancy after diagnosis being less than a year.
Psychiatry is a branch of medicine. It is imperative to rule out possible organic causes before diagnosing mental illness. Having said all that, I must emphasise that there are a significant number of patients who fit the diagnosis of ‘dysthymia’ and remain depressed for years. They do well with a long-term maintenance (small) dose of an antidepressant, but relapse on stopping the medication. Therapy helps. Some patients say they benefit greatly from yoga and meditation.
The next category in the DSM-5 is Anxiety Disorders.
Under this rubric are many conditions whose hallmark is crippling anxiety. Therefore, treatment depends on the specific diagnosis. They usually need a short course of medication to control anxiety, followed by therapy.
Obsessive-Compulsive and related Disorders is the next category of mental illness listed. This also includes trichotillomania (hair-pulling), excoriation (skin-picking) and body image distortions.
As the prevalence of OCD is 2-3% of the population anywhere in the world, it is rather common and presents with a variety of symptoms. However, as symptoms come in phases, patients initially dismiss them as habits that will go away in a few months. So they often come for a consultation many years after onset.
Medicines work extremely well in more than 90% of patients. They are happy to get their lives back on track, with no unwarranted worries about checking locks, replacing objects just so, repeatedly washing hands, counting stuff, time-consuming rituals, useless rumination, etc. But when realisation dawns, there is much regret about grades lost, opportunities missed and suffering endured over the years, especially as the average age of onset is about the time kids are in high school or college. Awareness about OCD has risen enough for the acronym to have entered common parlance. It will hopefully translate into early treatment of sufferers.
Well, there are several more categories listed in the DSM-5, but they are not common in clinical practice and can be dealt with better by clinical psychologists, sexologists, or by a team of people from different disciplines in Psychiatry departments of hospitals, for example Eating Disorders, Substance-Related Disorders, Sexual Dysfunctions and Relational Problems.
Regarding Sleep-Wake Disorders, insomnia connected with anxiety and depression usually gets better with treatment of the underlying problems, but primary insomnia is harder to treat. Patients are first advised to maintain ‘sleep hygiene’ for a few days and see if it makes a difference. If there’s no change, a trial of a hypnotic is given for a maximum of one month, which sometimes seems to reset the sleep rhythm. However, this could be a placebo effect. If this happy outcome does not take place I refer them to a clinical psychologist for cognitive therapy. A sleep study in a sleep lab may help find the cause, but that can wait.
Sleep-wake disorders have a biological basis in circadian rhythms, an area of active research. In fact, this year’s Nobel prize for Medicine went to people working on circadian rhythms.
The last category I want to draw attention to is Personality Disorders.
These are people whose way of being doesn’t fit in with what is considered normal. Their problems usually arise when they have to interact with people, because of being any of these: aloof, mistrustful, awkward, remorseless, deceitful, intense, unstable identity, attention-seeking, grandiose, inhibited, submissive, clingy, rigid, perfectionistic.
Most of them function as well as ‘normal’ people a lot of the time. Like anyone else, they come for a consultation when they have a problem and are upset – angry, sad, anxious, confused, sleepless, unable to concentrate. The personality traits that have caused them grief become apparent to me during the next two or three review visits. However, they are satisfied when their presenting symptom is taken care of and are not interested in going deeper.
Some of them are prone to brief psychotic episodes lasting a couple of days at a time, when they lose touch with reality and become angry, violent, destructive or suicidal. This is how they wind up being brought to the hospital in an emergency.
When an unusual crime is committed, ‘mental illness’ is often the first conclusion, e.g. Stephen Paddock in Las Vegas recently. Even if Paddock had inherited a genetic predisposition to Antisocial Personality Disorder from his father’s side it need not have manifested at all. He functioned well enough for 64 years. Looking at his life from other angles, contributory factors could be:
- sociological – family background and milieu
- psychological – childhood, parenting, risk-taking behaviour
- medical – use/abuse of a psychotropic drug
- ?religious – apparent lack of a moral compass
- ?philosophical – lack of direction
A prescription for Valium dated 10 June 2017 was found in his hotel room. Had he been diagnosed dangerously mentally ill, he wouldn’t have been prescribed only Valium. Since no motive has been established, what if Valium use/abuse triggered aggressive behaviour?
Whereas Devin Kelley, who sprayed bullets into a congregation in a church in Texas a couple of days ago, was certainly mentally ill, going by his history as reported in the media.
Is the human race getting more despicable, or are people simply adapting to the rot they are steeped in? Integrating education, psychology, sociology, religion, ethics, environmental science, economics and political science (and whatever else) into a ‘theory of everything’ to raise children well – maybe this should be the job of people working in public mental health. ‘Can a bent plant be straightened after it grows into a tree?’ is a Kannada saying that sums it up well. Apparently it can, but needs the botanical equivalent of therapy.
Psychiatrists are frequently accused of medicalising mental illness. Yes, I certainly believe there is biology underlying every single thing that happens to a human being. Why not, when the body is made out of oxygen, hydrogen, carbon, nitrogen and other elements? For example, it was suspected from the 1800s that schizophrenia has a biological basis, but facilities for research were inadequate; now there’s a huge body of research that proves schizophrenia is a neurodevelopmental disorder. The exact neurobiology of mental illnesses is something we must continue to look for, not give up on.
Decades passed between Dalton’s introduction of his Atomic Theory and the discovery of leptons. Complicated computer codes are ultimately just arrangements of 1s and 0s, and Artificial intelligence using just 1s and 0s is now set to replace human minds. (I can’t help thinking Elon Musk, Stephen Hawking and Bill Gates may be right in cautioning AI enthusiasts, though.) Everything has a starting point, things don’t suddenly appear out of thin air, and researchers in every field try to get to the bottom of things.
To conclude, I believe that psychiatry is a medical discipline and psychiatrists can only
- recognise and institute management of medical problems that present with mental symptoms,
- intervene in crises like psychotic breakdowns, manic episodes and suicidal attempts, where patients are in physical danger,
- treat mental illnesses that interfere so much with a patient’s biological, social and occupational functioning that he cannot have anything approximating a normal life without the help of medicines, and
- provide counselling and supportive psychotherapy of an eclectic kind that includes elements of cognitive therapy, interpersonal therapy and gestalt therapy.
drshyamalavatsa 