When soul meets body

“Come on babe, we need to get closer! It looks like there’s a gap ahead.”

We pushed through the crowd and finally got within ear-bleeding distance of the stage. We arrived at the gap we had seen from some ways away, and were met with a small pond in the center of the concert ground. I guess we hadn’t added two and two when we went to this concert on a beach, and heard, almost incessantly along the way that, “the lake was up.”

We had become one with the lake.

65197096_159513941754770_6094586745271158401_n The evening was a Thursday in June and my partner and I had just seen one of my favourite bands, Death Cab for Cutie. Death Cab found their fame in the mid-2000’s, a time which I was unsurprisingly in high school. Why unsurprising?

The spiritual relationship between a person and music is difficult to put into words. Music, for most of us, represents something transcendent, the simultaneous embodiment and understanding of our soul by vocalist and band. Music makes us feel connected and understood, not only by the artists standing before us, but by each other. Some of the closest friendships and bonds have formed through collective belting of the latest punk song on the fringes of a bloody mosh pit. Somehow, you arrive at the conclusion that, this person gets me, based purely on the fact that they also didn’t mess up the end of, “Northern Lights.”

The point is, music, for many of us, represents identity, on an existential level, and our sense of identity begins to solidify as a teenager. Not a coincidence I love crappy mid-2000’s punk and emo, my father loves Deep Purple, and his father some old guy on a scratchy microphone.

The role of music in expression cannot be understated. Whether it’s singing, “What’s My Age Again?” in your 2001 Corolla with your friends, or tearfully singing, “Always,” to yourself in the shower, music allows us to understand, express, and manage our own emotions to a higher degree.

62021206_213464446295848_7931776062685125866_n On a primitive level, we were built for this. The part of the brain that understands music is actually completely separate from the part of the brain that controls language. There are types of strokes where people who cannot communicate through speech find success in communicating through music. Late stage Alzheimer’s can often preserve the music centre, long after language has been coldly taken away.

This part of the brain also develops earlier in human development than the language centre. Instead of a chicken/egg phenomenon, the answer here is clear. Music came first! This may be why babies coos in musical tunes, long before they tell you, “give me that food!” The point being music, in humans, gets at something primal, ancient, and fundamental to our existence.

Do you have a favourite band or song that seems to bee your go to during times of happiness or sadness? Leave it in the comments!

Dr. Travis Barron is a resident physician in Toronto, Canada.

Goodbye Psychiatry, I’ll miss you!

Getting off of the 501 streetcar, I realized this may be the last time I make this trip for a while. I soaked in the Ossington Avenue intersection, after almost being ran-over by a passing car (ah, the familiar feeling), and walked towards the doors of the Centre for Addiction and Mental Health (CAMH). As I peered at the campus, my sense of loss was accented with fondness and the strange intervention of excitement at what is to come.

I had officially departed the Department of Psychiatry, and joined the Department of Family Medicine.

19623600_1882847292039496_9104144131264872448_n I know what you’re thinking. This guy with the mental health blog, leaving psychiatry? That doesn’t make any sense!

All I can say is, we all have our own journey.

During my time in psychiatry, I worked in a variety of hospitals across the city of Toronto, CAMH being among the most memorable. I had the privilege of working with some of the world’s – that’s rights, world’s – leading experts in mental health. It was truly an honour. Psychiatry has given me more than I can possibly express through the lens of a blog post. I know that because of the Department, I am a better person, and a better physician.

So what gives? I just wasn’t happy.

The supervisors and colleagues I have worked with in psychiatry have done, and will continue to do, amazing work and help heal some of society’s most marginalized. For myself, the opportunity to see a broader variety of people, and be more of a utilitarian with my skills, as opposed to a specialist, has come to reveal itself as important to my happiness. I remain passionate about mental health. Every single one of us is touched by mental illness, in some way. There isn’t a patient that presents to a physician anywhere in this country who hasn’t been influenced by their own psychology.

_DSC3796 The absence of a mental health system in Ontario has played a role in this difficult decision. The number of times I have recommended CBT to someone, knowing their options are 1-2 year waitlist or out-of-pocket, is heartbreaking. Discharging severely unwell people, with attenuated psychotic symptoms, or severe drug addiction, to the street, because the waitlists for supported mental health housing can be almost a decade, is gut wrenching.

This is no fault of my amazing colleagues, who at this very moment continue to fight and advocate for the patients for which they care. Malignant neglect by the government’s of this province – and frankly, the country – have resulted in a patchy system with too many holes.

It’s not all bad – change is coming. The programs CAMH continues to create and advocate for are world-class and industry-leading. But as I am sure many of you know, there remains a way to go.

Which for me, means it’s time to move on. And I’m excited. For new beginnings. For a change of pace. For brighter days. And for my General Surgery rotation (just kidding, terrified about that one!)

Goodbye Psychiatry, I’ll miss you.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Were we meant to be alone?

“Ha, that’s fun!” he said to himself as he looked into the camera, jovially laughing as he honked his air horn at the nonexistent mice he thought may be living in his shelter.

Meanwhile, the audience, myself included, were simply marveling at the extent this man’s beard had grown while he spent two months entirely ALONE in the Mongolian wilderness.

If you’re not sure what I’m walking about, I’m referring to The History Channel’s amazing new show, Alone. In a nutshell, the show takes ten survival experts and drops them off in the remote wilderness, entirely alone. They give them a camera to film themselves and a wireless phone to call into the crew and, “tap out.” How do you win? Last the longest.

The effect of the show is remarkable; very quickly you can observe the mood fluctuations among the participants. Careful, calm experts quickly see the onset of sometimes game-ending impulsivity. Suspicion and paranoia often sets in at the later stages, not unlike the collective psychosis shared by the cast of “Lost.”

It’s impossible to watch the show and not wonder, were we meant to be alone?

The effects of loneliness on the human mind are well documented. Loneliness can both contribute to and perpetuate a depressive episode, and loneliness is one of the number one risk factors for suicide. In Borderline Personality Disorder, one of the key features is an inability to be alone. This manifests as a fear of abandonment/intense interpersonal relationships, difficulties defining your own individual identity, and impulsivity.

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The effects of loneliness on dementia risk is one of the most astonishing revelations as we reflect on the effect of isolation on the human brain. Studies have shown that elders who endorsed feeling lonely had a 1.64 higher likelihood (that’s 164%!) of developing dementia than their non-lonely peers. Sadly, millions of older seniors in the developed world interact with absolutely nobody up to six days a week. How does loneliness affect the elderly brain? You can read my article on sleep hygiene and brain functioning here – the punchline is that our brain needs to be used to stay healthy. “If you don’t use it, you lose it.” Our brains are designed to be in relative constant conversation and use, and when people become socially isolated for two long, the brain literally starts to degrade.

What may be more surprising is the effect of loneliness on our physical health. Some studies have shown that loneliness has the same effect on cardiac health as smoking fifteen cigarettes a day! Finally, the effects of loneliness on mortality has been estimated at increasing your risk of death by 29%.

The average family size two centuries ago was 20-30. It wouldn’t be uncommon for that many people to share a small residence. While I am not recommending a return to this social structure, the effects of the decreasing family size in western society cannot be ignored. In more recent times, families that often had 10-12 member (it was not uncommon to have 7-8 children per family). Today, the average household in Canada, and much of the west, is four people and change.

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As our family sizes decrease, so do our supports. The increasing emphasis in western civilization on individuality and independence has caused many of our traditional social safety nets to degrade. It’s no coincidence that children apprehended by child protection do much better, on average, when there is an extended family member able to take custody of the child.

When I think about life-draining, isolating office jobs, I find myself wondering, “who the fuck doesn’t get depressed?” When I think about borderline personality disorder, and see the impulsivity, and mood fluctuations among the Alone contestants, I find myself wondering if I am simply watching the normal reaction to isolation. When I think about dementia and loneliness, I find myself disgusted, at the collective failure of our society to embrace the people who once stood before us.

I don’t think any of us were meant to be alone.

Editor’s note: Am I saying Borderline Personality doesn’t exist? No. It’s real, and can be serious. As with all psychiatric illnesses, social context matters, and people who have Borderline Personality may not necessarily find they would have had the same struggles in social functioning if our social structure was a little different!

Dr. Travis Barron is a resident physician in Toronto, Canada.

Why can’t I sleep?

BKN Raptors Return 20190615 — Credit: CityNews Toronto

You’ve just finished watching the Toronto Raptors win their FIRST NBA championship in history. You smile at yourself for being so smart as to get this awesome 60″ plasma screen TV installed in your bedroom. You belt out one last rendition of “O Canada,” before you check the time and realize, “oh fuck it’s almost midnight!”

You hurry off to bed, and give half an honest effort to brushing your teeth in a slight haze as you digest the half dozen beer you drank over the last three and a half hours.

Finally. Bed. You lay down and close your eyes, just to be flooded with images of – Kentucky Fried Chicken?! You think that’s odd, before you remember the commercial for KFC playing repeatedly throughout the game.

You wonder, “why can’t I sleep?”

Your brain is essentially a large glob of fat, composed of microscopic cells, that act like wires. Likes wires, the cells connect to each other. Brain functioning in every domain – think attention, cognition, mood, vision, movement, everything you can imagine – is not about the individual brain cells, but rather, how the cells connect to each other.

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Why is this important? We have a saying in medicine that goes like, “neurons that fire together wire together.” That means that in a baby, the cells in the brain are essentially randomly connected, with very weak connections, and the end result is very little complex behaviour. Over time, as a baby matures into a child into a teen into an adult, they use their brain more, and the brain recognizes what connections are being used. The brain reinforces and strengthens those connections, and gets rid of, “or prunes,” extra connections that are needlessly using up energy. (As a side note, this neurological phenomenon is also behind the old adage, “if you don’t use it, you lose it!”)

The end result is that the brain becomes very good at recognizing patterns. I promise that’s all of the complicated brain science!

This ability to recognize patterns is why when you smell baking blueberry pie, you may think of your grandmother. It’s why a caveman, when he smells bison scat in the air, might think there’s a herd nearby. This is an over simplification of the human brain, but on a surface level, the evolutionary benefit of pattern recognition is obvious.

As things go, in our modern day society, this ability for patter recognition can sometimes cause us harm. In particular, in bed.

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The number one environmental factor I see in my clinic that contributes to insomnia is screen time in the bedroom. When people spend time in bed on their cellphone, answering emails, using a laptop, or watching TV, the brain learns to associate the bedroom with a place where work is done. Train your brain to read emails in bed too often, and that’s where your brain will immediately go when you lay your head down to rest, even if you’re on vacation and haven’t received an email in two weeks. I recommend to patients that cellphones be charged at night outside of the bedroom, and that there should not be a TV in the bedroom. I myself can attest to this – when I was in medical school, I had roommates, and all of my belongings in the world (including the TV) were in my bedroom. Since beginning residency, I don’t have roommates, and I get to sleep incredibly easier, now that my TV is in the living room!

You should also not spend time in bed awake. What do I mean? If it’s late at night, and you just can’t seem to fall asleep, get up! Go in another room, and sit down for a few minutes. Some people might read a chapter of a calm book under low light for a few minutes. Once you feel tired again, which is usually within fifteen minutes, go back to bed. This way, your brain begins to associate the bed with sleep. The more often you practice this, the better reinforced those brain connections get, and it gets easier and easier. As we say in the field, the only things you should do in bed, are sleep and sex!

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Finally, we can also use our brain’s super powered pattern-recognition to our advantage, with having regularity to our sleep schedules. This means going to bed and waking up at the same time, each and every day, even if you don’t feel too tired at one, point, or really want to sleep in the next day (I give you a free pass on Saturday’s). This can be difficult at first and you may find you become slightly under slept. Don’t worry, hang in there! I promise that it will get easier, with practice!

Hopefully you find this helps you and your sleeping patterns (ba-dum-pshhhhh)!

Editor’s Note: Stay tuned for more on sleep hygiene and the effect of day/night cycles on sleep!

Dr. Travis Barron is a resident physician in Toronto, Canada.

The first patient I cured

“So ya, that’s everything that’s going on…”

There was a long silence before I responded, “that fucking sucks, it really does.”

“You’re telling me…”

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I had just started as a resident doctor at a hospital in Ontario, Canada, and was working with one of the first patients I would ever follow in my outpatient psychiatry clinic. I met a woman, Ms. G, who worked as an engineer. Ms. G had been referred to the clinic by her family physician (known as a general practitioner outside of Canada) for an assessment of low mood and sleep disturbance.

As these things go, you get some information in advance of the consultation from the referral form. Ms. G had never been involved with the mental health system. She was in her 50’s, married, and had three adult children. She was also not presently taking any medications.

I’m excited. A blank slate, a canvas ready to be worked with. So much potential. I quickly opened my copy of Prescriber’s Guide, and reviewed the starting doses for all of the basic antidepressants. Would today be my first fluoxetine start? Sertraline? Maybe even escitalopram?

The consultation time quickly arrived and I stepped out into the waiting area to ask for my client. Ms. G was average height, was wearing business attire, and had been using her cellphone immediately prior to my arrival, which she peered at through a pair of thin, golden reading glasses. Ms. G shook my hand and we walked together to the office.

Ms. G and I spoke for almost an hour. She detailed her struggles with low mood, decreased enjoyment in life, poor sleep, poor appetite, and difficulties concentrating. There were profound feelings of guilt and worthlessness. Her mental status exam was actually relatively benign. You were certainly given the impression that this person was tired and frustrated, but you certainly weren’t put in mind of someone in the throes of a severe depressive episode. With this information, I was able to determine that Ms. G met criteria for a Major Depressive Episode, mild/moderate severity.

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Ms. G also owned her house. Her and her husband had just renovated the home, and it was beautiful. That was before the flood. A month prior, Ms. G’s home was the most recent victim in a spat of Toronto city floodings. Everything in the basement was destroyed. A lot of the renovations, which included the downstairs bar and family room, had not even been properly enjoyed yet, only to be destroyed by the flood. Even worse, Ms. G’s home was the only one on her block to sustain significant damage.

“that fucking sucks, it does.”

“You’re telling me…”

Our consultation wrapped up and it was time to discuss the impression, plan, and treatment with Ms. G.

“Based on everything we have discussed, your presentation is not suggestive of any mental illness.” This peaked her interest.

“Then how do you explain what’s going on? I can’t sleep, I feel awful all the time…”

“Well, you have a lot on the go. You just renovated your home, spent tens of thousands of dollars, and now you’re faced with the flood. In a way, you’re re-traumatized every single day when you get home from work and have to be reminded of the damage, since the repairs are yet to be done. It makes sense to feel this way.”

Ms. G liked my opinion and asked me what she could do to feel better. I told her to hang in there, and to continue working on the repairs. I told her my suspicion was that she would feel a lot better once the repairs were taken care of. She would be able to move on.

I also told her I did not expect medications to have any effect on her mood. This wasn’t depression. This was an exaggerated form of a really, really bad day. I did offer a short supply of some sleeping pills which she gladly accepted.

I also told her I wanted to see her again, and I followed up with her twice over the coming months. At the second follow up, she was smiling, and I noticed the bags under her eyes were quite less pronounced.

“Good morning doctor.”

“Good morning Ms. G. How are you today?”

“I’m great – you were right!”

“I tend to be,” I said as I laughed. “But just so we’re on the same page, what are you referring to?”

“It’s finally over.”

“The renovations?”

“Yes!”

“I’m so happy for you.”

“Thanks for everything, doc! You cured me.”

Editor’s note: I didn’t cure this woman – as these things often go, time in many ways heals most wounds. This was the natural history of getting through psychological distress following something like a home flooding. This is not what I would expect to happen with true and blue depression, which often needs a combination of therapy and medications.

Ms. G met criteria for depression; that does not mean she has depression. You can meet criteria for any number of mental illnesses, and it is up to you and your doctor to synthesize all of the available information, and to interpret it in the way that makes the most sense.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Depression-Go-Round

I’m not feeling great today, maybe I should skip the party…

“Hey, Jen! Are you coming?”

“No, I think I’m going to stay in.”

Later that night, you find yourself thinking, I’m such a failure, I’m so useless, I couldn’t even get to the party… And I’m not any kind of company right now…

When you have depression, it is absolutely exhausting. A big part of that is because it seems like this sick, endless loop. Like you’ve been cursed to listen to your least favourite song on repeat for the remainder of eternity.

People with depression often become progressively withdrawn over the course of their illness. Often times, people with depression will skip events because they feel like they are incapable of having fun. They may worry about ruining others’ evenings. In the immediacy, this strategy seems like the only tolerable option. In the long-term, social withdrawal, caused by depression, also exacerbates depression, which in turn leads to further avoidance.

These cycles of thinking and behaviour are well recognized in the field of psychiatry, and we utilize our understanding of this phenomenon to guide our treatments.

In broad strokes, psychiatric illnesses have two main modalities of treatment – medication and therapy based. They often work best in conjunction with each other. Today, I’ll be discussing cyclical behaviours and the role of cognitive behavioural therapy in the treatment of depression.

Cognitive behavioural therapy (CBT) is a manualized, evidence-based treatment for anxiety and depression. What does manualized mean? Don’t think of a guy on his couch discussing his relationship with his mother; that would be an open-ended psychotherapy, such as psychodynamic therapy. CBT is very specific, with worksheets, homework, and goals that are worked on by you and your therapist over a course of 2-4 months.

tfb CBT relies on a principle – that our thoughts, feelings, and behaviours are all related and that they inform each other. And this relationship is a two way street, Your thoughts inform your actions, and your actions inform your thoughts. Your feelings inform your actions and behaviours, and vice versa. I could go on.

In CBT, you and your therapist will work together to address all three of these elements simultaneously. Thought records and your time with your therapist are used to explore thoughts and feelings, and to understand how behaviours may have an impact on how you feel. Remember the cycle of depression and social avoidance.

tfbt Over time, you and your therapist hope to achieve cognitive restructuring – literally a change in the way you think. Instead of thinking, “I’m too tired for that party,” you might find yourself thinking, “I’m tired and I should go to the party for at least a few minutes – it will probably be fun.” Cognitive restructuring takes time, and considerable investment. It can be considered the “top down approach,” because it focuses on thoughts/the brain/the “top.”

A big – and underappreciated – aspect of CBT is behavioural activation, or the “bottom up approach.” When you’re depressed, and have been withdrawn for some time, it literally becomes difficult to have a positive thought. It also becomes easier to have negative thoughts, and you lose enjoyment in things you had previously found enjoyable. This isn’t just partying and socializing, but also things like laundry, and brushing your teeth, things that previously resulted in satisfaction but now seem insurmountable.

tfbb Behavioural activation acknowledges this disconnect and works to encourage people to do things anyway, despite the sense that no enjoyment or satisfaction will be wrought. Behavioural activation “kick starts” our brain, and gives us the ability to feel positive about things again. This can in turn make the cognitive restructuring arm of CBT a little easier, and before you know it, the cycle is working in the opposite direction, and improving your mood.

When I work on behavioural activation with patients, we often start with simple things such as brushing your teeth, or making your bed in the morning. We escalate the therapy progressively, and before you know it, the most out of reach goals are within the patients grasp.

I know when I started my residency, therapy seemed like a bit of an enigma. Now, I have a bit of an understanding, and it has empowered me. I hope I have been able to empower you!

Dr. Travis Barron is a resident physician in Toronto, Canada.

Language matters – Does everybody have mental illness?

“It’s my OCD.”

“She’s so bipolar.”

“He’s depressed.”

Does it ever seem like everybody nowadays has some sort of mental illness? Behaviours we find uncomfortable somehow explained by the latest acronym? They all have anxiety. Who doesn’t have depression?

That’s because everyone does have anxiety. Or at least, feelings of anxiety. And the same goes with depression. Anxiety has evolved inside of humans to serve vital functions. To be afraid of the lion stalking in the night. To think that standing precariously on the edge of a cliff might not be a good idea. Today, anxiety makes us on time for work. It helps us meet deadlines. Yes, it sometimes makes us feel uncomfortable, but can you imagine humans, without any anxiety? Not a society I want to live in.

Not everybody has Generalized Anxiety Disorder, or Major Depressive Disorder. These are mental illnesses; they are defined by criteria contained within a manual, the Diagnostic and Statistical Manual V (DSM-5). What makes these disorders different from anxiety, and sadness (colloquially known as depression nowadays)? They are pervasive in people’s lives and cause difficulties in functioning.

Mental health awareness is amazing and the reduce the stigma campaign has done wonders for mental health research and support for those suffering from mental illness. A side effect of this campaign has been the increasing use of psychiatric terminology in common speech, resulting in confusion between what a physician means when they use certain terms, or when a term is used on Instagram. This has always happened – the word “paranoid” being a great example – but we are seeing it happen at an increased rate due to social media.

The message? We all have anxiety, sadness, and rigid behaviours (often misdefined as OCD). It’s normal. Those traits probably make you stronger, to some degree. The presence of those features does not mean you have a mental illness. If you are worried you have a mental illness, you should see your doctor. They can often help.

Editor’s note: Mental illness is very real and very debilitating. But the stigma remains. Throughout my career I’ve worked with people from all walks of life, mental health skeptics included, and I’ve come to appreciate that at least some of their frustration comes from the fact that seemingly “normal,” well people are endorsing having mental illness. I think what they are describing is a good example of why language matters, so hopefully this can help!

Dr. Travis Barron is a resident physician in Toronto, Canada.

He’s biting again

“Mr. V is biting again.”

“God, what are we going to do with him?”

“I don’t know, but he’s getting too much to manage…”

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Dementia is a debilitating disease. It creeps up slowly, crouches for attack, and seems to suddenly wipe our lives from right beneath our feet.

Many of us have had loved ones stricken by the disease, and have watched in muted horror while the person we knew vanishes, as we wonder, “if it’s this bad for us, what must it be like for them?”

I was working in an emergency department in Ontario, Canada, when a gentleman, Mr. V, was brought in from his place of residence when staff determined he was too agitated for their care. On arrival, he could not speak beyond muttering a few nonsensical words, and would randomly grab at staff as they walked by, seemingly on a completely random basis. The staff at his residence confirmed he had a history of dementia.

These sort of patients are difficult for a variety of reasons. The inability to communicate often results in subtle needs going unmet, leading to aggression. They require a high level of nursing resources to manage. And the fact is, our healthcare systems in Canada (particularly emergency rooms) are not equipped to properly care for people with dementia (in fact, in many ways they are perfectly equipped to exacerbate symptoms of aggression in dementia).

I began to work with Mr. V and I immediately noticed his age – he was in his late fifties. This is a fairly young age to develop dementia and immediately the differential changes. Could he have some rare form of genetic Alzheimer’s, which can affect people at that age?

The second thing I noticed was has last name, changed for the purposes of this blog. The spelling on the name was immediately suspicious for someone of Sri Lankan descent. I phoned Mr. V’s emergency contact, and my suspicions were confirmed. Mr. V had a long history of alcohol abuse, and had subsequently developed a dementia. He had been various degrees of under-sheltered for the last number of years. He had immigrated to Canada some decades prior, as a refugee. Mr. V was Tamil and had been a victim of unnamed trauma during the Sri Lankan civil war.

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Credit: Alternative Press

I won’t go into details here, but the Sri Lankan civil war (1983-2009) was your typical civil war cocktail of genocide, torture, rape, and any number of unspeakable deeds. The effects of civil war and genocide on the human brain are well documented and not easily conceptualized. Obviously it has a tremendous impact on people, Mr. V being the latest example of a casualty of the war. The United Nations recently reported that one in five individuals in conflict zones suffer from a major mental illness, at any given time.

What struck me about this story was how succinct it was. The clear relationship between this man’s trauma, alcohol use, and dementia. The story isn’t always that clear. But there’s always a story. Next time you meet someone with an alcohol problem, dementia, or any other mental illness, stop and think, there’s more to the story.

Editor’s note: What happened to Mr. V? We uncovered an acute medical problem that was easily treated, superimposed on his dementia, and he returned to his baseline after a couple of days of treatment!

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.

There’s a microchip in my head

“Hi, welcome to our emergency room, what brings you in today?”

“I need to see a surgeon.”

“And why is that?”

“I need to get the microchips implanted in my brain removed.”

What is the role of a psychiatrist? Depending on who you ask, you’re likely to get many different answers. To help people. To make me feel better. To push pills. Population control. It’s a question I myself have struggled with time and time again throughout my career, and it would be a lie to tell you I knew the answer perfectly. In reality, a psychiatrist wears many hats, and many psychiatrists view their own roles quite differently, which is reflected in how they practice.

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I was a wee-medical student in Ontario, Canada, working in the emergency department one summer. We had a gentleman come in and request to see a surgeon to remove microchips from his brain that he felt were responsible for broadcasting his thoughts to the public.

In Canada, when you go to the emergency department, the first physician to assess you would be an Emergency Medicine physician. The doctor I worked with that day, Dr. S, asked me to go see the gentleman.

When I met him, he was tall, skinny (certainly not emaciated), and appeared a little anxious. He was far from the most distressed patient I had ever met and was not agitated whatsoever. I asked him the usual battery of questions and he denied being suicidal or wanting to harm anyone. He simply kept coming back to these microchips. “When is the surgeon going to come?”

I finished my assessment and thanked the gentleman for his time. I explained to him that in my experience, what he was experiencing could be best explained by a condition called psychosis. And good news! Psychosis is a condition that responds to medicine, and we are able to arrange for him to see a psychiatrist today if he is interested.

“When is the surgeon going to come?”

I excitedly headed towards the nursing station to review with my supervisor, confident that my diagnosis was correct and that my plan was solid.

“So, what do you think?”

“I think the most likely diagnosis is psychosis, probably secondary to schizophrenia based on his presentation.”

“Excellent, I agree. What would you like to do?”

“Well, I think we should consult psychiatry, send some antipsychotic labs, call his fam-“

“Wait a minute. Does he want to see a psychiatrist?”

“No, he thinks he needs to see a surgeon.”

My preceptor smiled and asked for my reasoning for treatment, and I explained that the guy is psychotic, he needs treatment. She disagreed.

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The patient was psychotic, this is true. He was not suicidal, he wasn’t violent. He wasn’t agitated, or emaciated. There was no real visible distress – certainly not close to the amount of distress involuntary admission to hospital and coercive treatment causes. And he didn’t want to see a psychiatrist. At the time, I was somewhat mystified at the idea of not treating someone with such profound symptoms that in all likelihood would have been at least somewhat amenable to treatment. I imagined this guy’s life coming together, all his problems solved with my little pill.

Today, I know better.

People are entitled to believe and feel what they want. I have no right to tell you how to feel or what to believe. Is believing you have microchips in your head so different than believing there is someone in the sky that created the earth in seven days? I’m not sure it is. What my job is, is to intervene at moments of risk. You can believe you have microchips in your head – if that becomes so intolerable you feel like you need to kill yourself, it is my duty to intervene and keep people safe. In the absence of risk, as the old adage goes in Newfoundland, more power to ya.

There is of course the argument about treating psychosis when it begins to impact people’s lives, but does not cause an immediate risk. Someone who gradually becomes homeless over time due to functional problems as a result of psychosis, for example. Think the guy talking to himself on the side of the street. Yes, these people would (likely) benefit from antipsychotic treatment, but only when it comes from their own free will. When medications are forced on people, they quit them the first chance they get.

So what is my job as a psychiatrist? To help. To be available. To sometimes intervene and violate free will when there is a risk of harm to someone. But not to tell you what to think, how to feel, or what to believe. That’s your own choice.

Editor’s Note: We did of course offer this gentleman ample follow up, and he politely refused everything we had to offer. What we find important here is making this gentleman feel safe when he comes to hospital so that when he does need us, he feels safe to come.

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.

Mental illnesses are made up (sort of)

You’ve experienced some swelling in your neck for the last three months and decide to see your doctor.

They do a physical exam and run some tests. At the follow up appointment, they give you the absolute last thing you wanted to hear.

“You have lymphoma.”

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When I started medical school, a memorable preceptor told me that I was about to learn an entirely new language. An understanding of that language, she said, would empower me to become a wonderful physician.

Hodgkin’s lymphoma is an example of a disease. What makes a disease? The presence of a clear, well-defined pathological phenomenon. Cancer is not a disease. And neither is lymphoma. Hodgkin’s lymphoma, however, is closer to the mark. Why does this matter? Because a disease is a very specific entity, and one that is by-and-large understood. It’s specificity allows us to target very specific elements of the disease, to develop treatment. There are (almost) no diseases in psychiatry.

Syndromes, or disorders, are clusters of symptoms that tend to appear together and suggest to the observer (usually a physician) the type of problem which may be going on. For example, someone presenting to an emergency department with swollen legs, shortness of breath, and chest pain, likely has heart failure (a syndrome; heart failure with preserved ejection fraction may be the disease). We have many syndromes in psychiatry. Someone presenting with an inability to get out of bed, tearfulness, and suicidal thoughts, may have depression. Someone who hears voices and believes they are being monitored by the CIA may have psychosis.

So why the disconnect? Because the brain is cool.

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The pathophysiology behind heart failure and lymphoma is relatively clear. This is not the case with mental illness. The human brain is extraordinarily complex, and is not easily studied under the microscope, or in labs with rats. It’s an exciting time in psychiatric research, as the human brain is in many ways considered the final frontier of medicine. For patients and individuals, it’s a frustrating time..

This ambiguity has caused us to rely on describing syndromes, as opposed to clear, well-defined diseases, in our practices. Syndromes, or disorders, can be seen all over psychiatry. Major Depressive Disorder. Generalized Anxiety Disorder. And I could go on.

Why is this important? A syndrome can be the result of a variety of things. Someone with chest pain, swollen legs, and shortness of breath, may also be having a heart attack. Someone presenting as depressed might have depression, bipolar disorder, hypothyroidism, or could be having a regular ol’ bad day. This helps explain why some people respond to medications, and why some do not. Why some people get great help from cognitive behavioural therapy, and others find it a waste of time. Since we’re dealing with a mixing pot of a variety of potential explanations, some trial and error is required as you and your doctor arrive at a suitable treatment. I get almost as frustrated as a patient when we are going through treatment and a medication doesn’t work, or a therapy isn’t suitable. It can be demoralizing to everybody involved. What can help is keeping in mind that that mystery and ambiguity are not unexpected, and are completely normal part of moving through the mental health system.

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.