Psycodex #A: 7 Reflections Across 7 Weeks

Candid reflections on observing psychiatrists as a student.

This is a reflection following a series of weekly primers on what Australian medical students learn in psychiatry. Past posts: Introduction, #1 Depression, #2 Mania, #3 Psychosis, #4 Addiction, #5 Anxiety.

Three books on the history of psychiatry at the British Library.

I have a love-hate relationship with psychiatry.

Love: The discipline deals with the most pressing problems of human experience. It sits in an unique intersection of medicine, neuroscience, philosophy, and sociology. You are forced to empathetically confront the consequences of society’s choices.

Hate: The discipline is tasked with problems it cannot deal with. There is no ground truth; it requires patience to wade through its uncertainty. You are forced to empathetically confront the human emotions and personalities that result from society’s choices.

7 weeks is short, but enough to start to feel the tension and cracks within the discipline. I rotated through a few different placements in public psychiatry: the acute mental health unit, drug & alcohol ward, community mental health team, and brief stints with emergency and consultant-liaison teams.

Ward rounds, patient-clinician conversations, home visits all piece together a glimpse into how mental illness is currently managed in psychiatry. Here are seven thoughts that stuck throughout these seven weeks.

1. Biology and classification aren’t enough.

Quickly, you notice how a classification system like the DSM-V falls apart in the face of the acute mental health unit. It’s useful as a research and communication tool, but limited clinically.

As your typical over-eager medical student, I barraged my consultant - who has practiced psychiatry in Serbia, the United States, and now Australia for more than 40 years - with a litany of questions. One double-question included: “How has the classification systems of psychiatry changed over time? How do you use it in your practice?”, to which he chuckled, and said something like: “You do what you can, with what you have.”

Quickly, I learnt what he meant. One of the first patients we saw was a woman (call her N) with a primary diagnosis of borderline personality disorder. N was clutching a small Stitch toy when she came into the meeting room. Soon, I realised this was because N believed herself to be fourteen years old. The consultant prompted her to look at her wristband, which put her age somewhere around 40-50, and she remarked it was strange that they’d given her the wrong birthdate.

Her reasons for being in the psychiatric ward was a chronic history of self-harm and mutilation, depression, anxiety, and bizarre delusions. She was consequently on a cocktail of drugs: antidepressants, antipsychotics, anxiolytics, etc. She was due for courses of electroconvulsive therapy, which appeared to help during her last stay.

N was given all the biological support psychiatry could offer. Classification achieved little - despite her diagnosis of BPD, she was still put on medications and treatments for her symptoms, and really, anything at all that the team thought would help her.

It is this biomedical narrative of psychiatry that suggests conditions like schizophrenia or bipolar disorder have genetic predispositions, which are unmasked by social/psychological triggers. As such, the base role of the psychiatrist is to manage these conditions biologically through medication.

My experience of medicine so far has shown me that it is the biomedical in which doctors are typically best at; after all, it is what we are trained in. If you have a patient with a stable socioeconomic background and some strong social supports, who is limited to these recurrent psychotic or manic episodes, the psychiatrist’s medical training and biological foundations act like a miracle.

Unfortunately, this is not the case for almost all the other patients you see in the public system.

2. Public psychiatry is where society deposits their undefined problems.

N represents a characteristic example of the ‘revolving door’ of psychiatry - patients get temporary relief, but they keep coming back. This is because whatever mental illness may exist in the individual, the unrelenting, perpetuating factors are socioeconomic. Can you get better if you don’t have a job? Can you get better if you don’t have a home? Can you get better if no one loves you?

Some call this ‘shitty-life syndrome’. I’ve come to the conclusion that this reflects the ultimate role of public psychiatry in society: to care for its undefined ‘problems’.

If you’ve committed a crime, you go to jail. But if you have a mental illness or personality which leads to social isolation, which then leads to suicidal or societally damaging behaviour, you go to the psych ward.

As the psychiatrist, one is left with the ramifications of various outcomes of society’s choices: economic inequality, drug policies, cultural disintegration… It is in the psych ward that these are all tangibly, viscerally felt.

And so, you are forced to do what you can, with what you have.

3. Psychiatrists are aware of their limitations.

I came into psychiatry perhaps more cynical than most. I’ve had enough close friends tell me about their ADHD-pill-popping psychiatrists and antagonistic run-ins with public systems. I had a negatively skewed perception of psychiatrists wanting to do good.

But whether it was the hospital I was placed at, or the environments I was in,all of the psychiatrists I shadowed were well-intentioned and competent. They varied in terms of knowledge, specialisation, and ability, but I strongly felt that they were humble in their knowledge, strong in their ethics, and painfully aware of their limitations as doctors. Of course, these clinicians are humans too. Dealing with this level of emotional burden, one can sympathise with the inevitability of burnout.

I’m certain that this is not the universal case (there are bad actors in every profession), but it also updated my overall view of the median psychiatrist.

I found myself thoroughly enjoying the grand rounds and journal clubs which critiqued existing paradigms, explored nuanced questions, and often led to sociological or philosophical discussions. Most of all, I felt inspired by this force of human good that continued to persist in spite of everything.

4. Psychiatry practices in a schism of active philosophical debate.

One of the biggest tensions for both the discipline and those that we treat is the question of whether psychiatric illnesses are really ‘diseases’. The arguments often go: Is depression just laziness? Is mania just excess emotion? These conversations happen in countless circles, beyond medicine and psychology, with differing opinions.

The consequences of this question are significant, since they lead to whether a group is treated with sympathy or with repugnance. When an individual kills someone, although the outcome is always horrific, there is a distinct difference, both legally and philosophically, between someone with a longstanding antisocial personality versus someone with a recently diagnosed frontal lobe tumour.

This is a complex topic at the precipice of philosophy and current modern culture. Scott Alexander provides a concise summary of the ethical tensions in his article Diseased Thinking, with some useful conclusions (see footnote (1) for my summary).

Regardless of one’s opinion on this debate, it is clear that those with mental illness are in a vulnerable position - it is difficult to self-advocate if you are in an irrational state, it is hard to have relationships when you are highly stigmatised by society, and you are ultimately at the whim of clinicians (that try to prevent harm to yourself and others). A philosophical change can help with some of these issues.

5. Psychiatry is culturally defined.

A key criteria of psychiatric illnesses in the modern DSM/ICD conception is the level of impairment to an individual in their work, relationships, and daily activities.

But normal behaviour in work and relationships is culturally defined. This is not a rigid, unchanging biological entity, but a dynamic social one that differs across different paradigms and contexts.

For instance, consider this: What if hearing voices in your head was normal? If you were a priest in the 1700s, you may take such voices as a sign from God. Nowadays, you might be diagnosed with schizophrenia, depending on whether these voices impair your daily function and are related to delusions or drugs. But this is not as rare as you might think; in fact, there is a whole Hearing Voices Movement (estimating around 2 - 6% of the population hears voices), that advocates for normalisation of this phenomenon.

There is nuanced debate here on whether hearing voices should be normalised, which is detailed well in another Alexander essay. There is a significant spectrum in severity of any symptom of the mind, and how society responds influences this symptom.

If you have behaviours that society shuns, you are socially isolated. If you are socially isolated, you may develop more behaviours that society shuns. It is impossible to push the blame purely onto an individual; it is society which moulds and shapes how we view individual characteristics.

This is the role that culture plays.

6. Psychiatry is politics and is imbued with power.

Although common to all medical disciplines, the cultural nature of psychiatry and its resultant lack of ground truth leads to a particularly strong political influence.

This is where the vice of human pride comes into play. If a treatment has more credence based on who is pioneering the treatment rather than the empiric efficacy of a treatment, we have politics.

Science has fought against this human urge through the scientific method and rationalism. Thus the science of psychiatry tries to rely on the same biomedical model of RCTs and meta-analyses, but there are effect sizes, significant placebo effects, and standardised results for every psychiatric treatment (see here for a brief exploration of what differentiates ‘wacky’ treatments). At a certain point, it feels like it’s more a question of who has enough funding to conduct the RCTs, rather than the RCTs themselves being a source of truth.

Don’t get me wrong - psychiatry is an evolving discipline and the current incarnation of symptom-based scales, standardised diagnostic textbooks is a far cry better than the wild west prior. But this still does not feel enough; particularly when psychiatrists hold such power.

Psychiatry is the only discipline in medicine which is intimately tied to the law. Sure, other clinicians can act as expert witnesses (or be tried as a defendant), but public psychiatrists engage with the law everyday - scheduling patients against their will, attending tribunals to argue for why a patient needs to stay, etc. There is even a subspecialty of forensic psychiatry, which specifically applies psychiatric expert testimony to criminal cases.

As a result of this power, It is unsurprising that there are activist critiques against psychiatry - Thomas Szasz (ironically, a psychiatrist against involuntary commitment), Robert Whitaker (journalist, founder of Mad in America), James Davies (psychotherapist and author) to name a few, advocate against specific political issues such as overmedicalisation, the excess lobby of pharmaceutical companies, and institutionalisation via asylums.

My wishful hope is that through better scientific understanding, we can reduce some of the politicking and have a more shared understanding of truth. Until then, individual practitioners have to make judgement calls.

7. Neuroscience can lead to scientific truth but currently serves as gospel.

If power is the first sin, the second sin of psychiatry is an overinterpretation of neuroscientific literature. I find that certain clinicians tend to oscillate between two poles: 1) we know nothing about the brain, and 2) this brain region is responsible for your X symptom.

This is perhaps true of all neuroscience communicators - the brain is a tricky organ, and doesn’t have simpler linear functions like the rest of the body (although truly modelling any organ is incredibly difficult).

Psychiatry texts all reference neuroanatomical findings and attempt to synthesise the current literature. But the issue is that there is no clean prediction of “X neuroscientific finding leads to Y mental symptom”. It’s all correlational.

We are then left with this tricky interplay; scientific theory is often used to communicate and build trust with patients, but we know that many reductive explanatory hypotheses are insufficient. Consider the monoamine hypothesis in depression, or the dopamine hypothesis in schizophrenia. They are useful to justify a simple story for medications (and helpful for understanding side effects), but lack any more true explanatory utility beyond this.

A new wave of explanations center on brain network theory-based deficits of the brain instead - implying several networks of the brain are dysfunctional in different psychiatric conditions. One example is Transcranial Magnetic Stimulation, where psychiatrists explicitly talk about these brain networks as the target for the magnetic coil pulses. This presents an early example of neuroscientific translation, but still leaves much to be desired: Are we just re-using the old monoamine paradigm, but now with networks?

Psychiatrists are in this tricky position of needing to clinically practice in a very much developing science, cautiously differentiating between what has been medically or scientifically proven, and what is hearsay. Hence - as most psychiatrists I’ve shadowed pressed - the importance of humility.

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All of these tensions in psychiatry make it infinitely interesting to study, learn, and (hopefully) practice.

It also makes it infinitely frustrating when treatments have limited effect, infuriating when there are systemic problems out of your locus of control, and, hopeless, when people take their own lives.

Psychiatry is plagued with attempts to come to better treatments, better philosophies, and better ways to deal with the mentally ill. When one combs through history, it is unclear how much we’ve achieved - perhaps we need a new discipline of progress studies focused on improving psychiatry.

But life is full of hard problems, which touch us to our deep, emotional cores. I think my final reflection at the end of my rotations has been: Why not work on something meaningful?

”Somebody has to, and no one else will.”

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(1) Society currently follows a deontological libertarian theory of blame. This means that individuals have free will, constrained by biology and circumstance. Thus, if there is no biological cause for the behaviour, the person is deemed bad. The issue here, is that psychiatric conditions often lie on the margin between biology and spirituality - depression clearly has biological manifestations, but it also feels in the realm of free will. This is distinctly unlike cancer, which has such clear biological causes which thus warrants sympathy.

The alternative view is the determinist consequentialist theory of blame. This believes that it’s all biology - but some behaviours are more affected by social influences (such as introspection, praise, condemnation). The consequentialist then believes that we should consider behaviour bad if and only if it leads to better consequences. Here, we give those with depression sympathy and condemnation in the pursuit of which actions help the individual.

I am in favour of the latter; a healthy balance between sympathy for those who suffer, and societal/cultural regulation of negative behaviour.