What is Psychiatry all about?
What goes on with the mind and the mood that makes it difficult to blend seamlessly with many aspects of life and the sense of joy and satisfaction?Why is it that sometimes we need to chemically induce happiness, trust, pleasure, interest, motivation, logical thinking, etc. ?Humans across cultures are equipped with a natural ability to evaluate reality, react to events in their environment with a wide spectrum of emotions and ways of thinking. The expression of such adaptability is varied from culture to culture. When faced with unfavorable events all cultures share in common the ability to restore happiness after sadness, calm after frustration, peace after fear, trust after doubt, engagement after indifference, focus after distraction, and reason when presented by evidence.Societal norms, spiritual values/practices and emotional intelligence provide a strong foundation that help us restore regulation after imbalance in a timely manner.Why is it that for some, this is not possible despite all personal and environmental interventions ?
Historical Background
Many attempts to understand the psychodynamic bases of emotional dysregualtion took place during the last century. Psychotherapy theories and environmental modification techniques were practiced, but with partial results. Hence, the fields of neuroscience, neurobiology, and neuropsychiatry evolved.
These fields scientifically study the brain anatomy and function. Initially the brain surface was mapped into areas corresponding to different sensation and motor functions. Deeper brain structures were studied comparing autopsies of normal brains to those with a history of emotional or mental dysregulation. Microscopic and Electron Microscopic studies were able to identify significant structural and functional changes in several psychiatric conditions as compared to normal population. Studies of the different chemicals( also called Neurotransmitters ) and hormones present in the blood and the cerebrospinal fluid (the fluid that circulates within the brain and the spinal space) showed further changes. More recent Positron Emission Tomography (PET), structural and functional Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT), showed further significant structural and functional changes in this population.
Observations
The observations that some illicit substances or alcohol can temporarily induce psychiatric like symptoms, such as hallucinations, paranoia, depression, irritability, violence, mania etc. These observations gave more insight into the presence of similar naturally occurring chemicals in the brain that are involved in the pathophysiology of psychiatric conditions. Medications usually can treat the abnormalities that are induced biologically, environmentally, or both.
Area of the brain that play central roles in emotional regulation, have been identified and mapped. Among these areas are the hippocampus, the striatum, hypothalamus, thalamus, nucleus accumbens, raphe nucleus, locus coeruleus and amygdala, just to mention a few. These regions are connected to each other and almost all other structures of the brain. Some communicate with the rest of the body via the spinal cord.
Environment
Effects of the environment on inducing or improving psychiatric conditions are significant.
If a biologically identical twin suffers from a psychiatric condition, his or her other twin has only a 50% chance of developing the same condition. Condition of significant biological predisposition can be triggered or suppressed by different environmental circumstances. Favorable environmental conditions are protective whereas stressful ones are triggering.
Research throughout the world has demonstrated over and over again similar biological, genetic and environmental factors contributing to psychiatric conditions across cultures and beliefs.
How much do we know?
Unfortunately we still don’t have the tools to know precisely who is going to develop what psychiatric condition at when. We do know factors that may increase the risk of developing certain conditions. These are more predictive than causative.
It is not within our capacity to safely obtain biopsies from target structures in the brain of living affected humans. This limits our ability to directly analyze each of the abnormalities and obtain direct evidence of their relationship to different psychiatric conditions. On the other hand, biopsies of other living human organs are routinely obtained, abnormalities are discovered, and through evidence specific treatments are guided. In a diabetic patient for example, a biopsy of the pancreas is obtained and studied. Abnormalities of the insulin producing cells are detected and used as direct evidence to guide treatment. In psychiatric research the tissue samples are obtained from autopsied brains of affected humans . This is done upon a consent from patients before death. Sadly, not many are interested in providing their brain to research. This is a major impediment in the progress of the field of psychiatry compared to other fields of medicine. In psychiatry most of the research data is obtained from living research animal brains, and body fluids of living human beings.
The research data available so far has lead to a number of psychoactive medications that have been extremely helpful in controlling some of the manifestations of psychiatric conditions but in no way are ultimate answers or cures.
Some major chemicals ( also called Neurotransmitters ) are:
Serotonin
Norepinephrine
Dopamine
Endorphins
Adrenocorticotrophic hormone (ACTH)( also called stress hormone)
Brain Derived Neurotropic Factor (BDNF)
Gamma Amino Butyric acid (GABA)
Glutamate
Acetyl Choline
What do Medications do?
Most psychiatric medications target one or multiple of the above neurotransmitters in an attempt to restore balance and improve related symptoms.
Psychiatric conditions are like medical conditions, they have signs and symptoms. For example depression is not necessarily the feeling of sadness, but could also be the mere lack of the sense of pleasure or excitement(anhedonia). In addition, significant physical and mental symptoms accompany sadness or anhedonia, like change in sleep, poor concentration, low energy, body fatigue, change in appetite, self deprecating thoughts, low self esteem, guilt, and sometimes suicidal thoughts.
Different conditions have similar symptoms. Each symptom is not diagnostic of a particular condition. It is rather the constellation of certain symptoms that point to a particular condition.
What is the best treatment?
The approach to treating psychiatric condition is multi-disciplinary. It involves environmental interventions, psychotherapy, psychopharmacology and procedures including Electrical or Magnetic Stimulation of the brain or the Vagus nerve. Psychosurgery may rarely be necessary for some conditions.
Psychotherapy and environmental interventions are vital and necessary in almost all psychiatric conditions. There are several forms and durations of therapy ranging from a few sessions to life long treatment. Therapeutic strategies target different conditions.
Pharmacological interventions are commonly used. It is hard to predict which neurotransmitters or receptors are exactly involved in each condition. Therefore we use what is called Rational Polypharmacy, meaning using a combination of medications that act differently but complement each other in a rational way. We may start with one medication then depending on the response/tolerance, we may add or switch to others that target different neurotransmitters or receptors. Switching medications or a combination of several medications may be necessary to target different symptoms of one illness. For example, we may use an anti-anxiety medication to calm nervousness, a sleep aid to restore sleep, and a mood stabilizer to regulate mood symptoms. Similar medications can be used in different conditions, so medications treat symptoms rather than syndromes.
It takes the brain 3-4 weeks to respond to psychiatric medications. Patience, environmental interventions, and psychotherapy can help alleviate some symptoms until the medication takes effect.
Most current psychiatric medications have a fairly benign side effect profile. Some have potentially deadly side effects. It is extremely important for us to discuss all potential side effects so that we can collaborate on how to best prevent them or treat them when they occur.
Details about other modalities like Transcranial Magentic Stimulation(TMS), Vagus Nerve Stimulation(VNS), Deep Magentic Brain Stimulation(dMBS) and, Electroconvulsive Therapy(ECT) is provided in the Education link.
How is a Psychiatrist different from a Psychologist or a Counselor?
What is the difference between them? A Psychiatrist is a Medical Doctor who is specialized in the area of Psychiatry. They are trained in both medication management and psychotherapy. Psychiatrists have the authority to write prescriptions. Psychologists, Counselors or Social workers have a Masters or a Phd degree in their respective fields . They practice psychotherapy, but they are not trained or authorized to prescribe medications.
I hope this general introduction was helpful in understanding the works of the mind and mood.
Ghadeer Okayli, MD
Board Certified Psychiatrist.