Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.
Have you ever seen a kid walking in the mall (sorry Gen Z), jumping from small blue tile to small blue tile?
“Avoid the lava!”
“Watch out for the monsters!”
This is a completely normal behaviour, and many children, including myself, dabble a little in the lava-tile game.
But imagine if to you, it meant a little more. Imagine that your found yourself unable to walk on white tiles, because of a crippling sense of anxiety that if you did, something bad would happen. You would probably know this doesn’t make much sense, which only adds to the madness.
It wouldn’t be easy going to the mall.
This type of behaviour, in it’s extreme form, falls under the umbrella of a symmetry/numeracy based obsession. In this type of OCD, the obsessional thought is usually something along the lines of, “if this isn’t this way, than something bad will happen.” There may or may not be a specific type of “bad”-consequence perceived. Some examples;
***
An eight year old boy goes through the home and makes sure every single TV and computer has the volume set on an even number. His father has the TV on 15 one day, and the child gets very upset and throws a temper tantrum when his father doesn’t let him change it. The next day, his mother asks him what happened. The boy responds, “if the numbers are odd numbers, I’ll die.”
A twenty four year old woman is late for work every day. She’s eventually fired from her job, and ends up in a doctor’s office while she is off of work. “I think I need help doctor.” “OK. You’re in the right place. What do you think is going on?” “Every time I look in a mirror, I can’t leave until I catch my nose at the perfect angle, perfectly symmetric. I don’t know why, I just can’t. Some days it takes up eight or more hours.”
A fifteen year old is teased at school for his quirky behaviour. He doesn’t tell his parents why, and they only know that he is being bullied. One day, when dad is picking the boy up from school, dad notices the boy jumping from dark tile to dark tile on the sidewalk. “What was that about?” dad asks when the boy gets in the car. The boy blushes and says, “can we just go?”
***
These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.
Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.
Doubt
Sometimes, OCD can be obvious. Other times, it is more nuanced. This is the case with obsessional doubt, one of the most common, but under-recognized, subtypes of OCD.
So what makes doubt obsessional? To understand that, we need to remember what makes an obsession an obsession. An obsessional thought is unwanted, and comes about seemingly out of our control. This is called an intrusive thought. Obsessional thoughts occur over and over again, and won’t go away. Importantly, obsessional thoughts consume a significant amount of time, and result in a functional impact. Remember, if it’s not causing you problems, it’s not a disease!
Taken all together, obsessional doubt occurs when someone repeatedly doubts they have remembered something. Obsessional doubt is also often coupled with compulsions, to relieve the anxiety associated with the doubt. Compulsions in doubt-based OCD tend to complement the doubt, and therefore the compulsions tend to be reassurance-based. Now I know this sounds underwhelming, but trust me, it can be debilitating. The following are some examples of people I have met (with their stories altered, of course) with obsessional doubt.
***
Richard was a 27 year old man living in Toronto. He was getting ready to go out on a date one evening and found himself very anxious. He was getting ready to head out, and had the sense he had forgotten to turn off the stove. He checked the stove and realized it was off. He did this two hundred and twenty two times, for good luck. Before he knew it, he had missed his date.
Dema was a 29 year old female admitted to an inpatient psychiatric ward for severe OCD. During rounds one morning, the word “complete,” was mentioned. Dema fixated on the word and became unable to answer any other questions. She repeatedly asked I repeat the word, “complete,” so that she could ensure she had heard me pronounce it correctly.
Mohammad was a 17 year old young man. He presented to my office one day complaining of difficulties studying. He found himself unable to move beyond the first few pages of his notes, as he felt he had to perfectly memorize everything if he were to succeed. He reflected on a similar incident a year prior, where he developed a fear he would forget his memories with a family member. He would repeatedly look at pictures of the memories he had, to ensure they were real memories. This would take hours a day.
***
These are real examples of OCD at it’s strongest. Fortunately, most of the people in the above example recovered reasonably well. Why share this? OCD remains one of the most under-recognized mental illnesses, and hopefully this helps dispel some of the myths.
You walk to Tim’s and you begin to realize you’re hungry. It’s 11:45 AM and lunch is only fifteen minutes away. You’ve brought your lunch to work today as well so you should be good.
Just a coffee, you say to yourself.
“Hi, welcome to Tim Horton’s! May I take your order?”
“Hi, yes I’ll have a large coffee with milk, a vanilla dip doughnut, and a pack of those doughnut sticks you have.”
What is it that makes fried, sugared dough addictive? Or deep-fried potatoes? Or sour patch kids? Or anything, for that matter?
In our brains, there exists something called the nucleus accumbens. This part of the brain is known as the reward centre. What does this mean? Every time you do something that feels good, this centre “pings,” and makes you feel good. Why does this part of the brain exist? Well, it’s actually essential to our survival! Things like eating, drinking water, and having sex, are vital biological functions for our species. Without them, we would not survive. Very few of us, however, are thinking about, “I need to survive and propagate my genes,” as we eat and have sex. No, most of us do these things because they feel good. That’s where the nucleus accumbens comes in. It pings and rewards us with a shot of dopamine, the brain’s “happiness chemical,” when you do something that’s good, biologically. It’s a built-in incentive system to ensure we are doing, and feel good about doing, those functions essential for species survival.
This system, however, is imperfect, and it is prone to being hijacked. The nucleus accumbens is where many substances of abuse act, including cocaine, crystal meth, and any number of drugs. This is why many people with drug addiction become very skinny, and can waste away. The drugs hijack the system, and reward you more than food. Drugs steadily train the brain that the best rewards come from the drugs, and not food or water or sex. A great example of how strong the craving for drugs can be is a study that examined rats, who had electrodes placed in their brain at the site of the nucleus accumbens. The rats were given the ability to hit a button in their cages, which would activate the electrode, stimulate the nucleus, and cause a reward. The rats eventually choose to die while hitting the button, and totally neglect vital functions such as eating and drinking.
But what is it that makes a substance addictive? Sugary foods can be addictive and cause cravings, for example, while carrots almost certainly do not. Cocaine and crystal meth are extraordinarily addictive drugs, while ritaline and vyvanse, medications for ADHD which act similarly, are not. What is responsible for this difference?
We think we know!
The nucleus accumbens appears to be sensitive the the size of a potential reward. Finding a penny on the ground, for example, makes us feel a lot less better than finding a one hundred dollar bill. Biologically, this discrimination has allowed the brain to prioritize eating high caloric foods, over low caloric foods, although both may taste good. (This function would have evolved prior to the food-availability we experience today in the Western world – the drive to eat higher calorie foods is a clear disadvantage to many of us nowadays.) The same principle applies today, which is why sugary, fatty foods are so addictive. The sugar and the fat, the nutrients essential to life which are activating the nucleus accumbens in the first place, are higher in doughnuts than they are broccoli, and therefore we crave doughnuts. This is actually a great example of how the advantage of a particular behaviour, and whether it is a mental illness, depends entirely on context. A drive to eat high caloric foods would have previously been evolutionary essential – now it causes heart disease.
So what’s the deal with drugs?
Well, the same principle applies. The strength of a stimulus is directly proportional to how addictive the substance is. So what affects the strength? Food that are higher in sugar and fat cause a higher level of nucleus stimulation, therefore we crave food that are slowly killing us. This is also true for drugs of abuse; crystal meth is several orders of magnitude stronger than cocaine, and meth is a hell of a lot more addictive. But there’s more! The speed of the stimulus also matters!
When a sugar/fat/drug reward is given to us suddenly, the nucleus reacts more strongly to it, and we get a higher reward. This also reinforces the strength of an addiction. This has implications for food, which is why a banana and a candy with the exact same amount of sugar make us feel differently. The candy which instantly digests and gives us a sudden jolt of sugar, is highly addictive. The banana, which takes time to digest and releases the same amount of sugar, just over time, is not addictive!
This principle also applies for drugs, and gets to the root of why ADHD medications are not addictive – usually. The medications used for ADHD tend to digest very slowly, and although they act on the brain in the exact same way as cocaine and crystal meth, are not addictive. This is because that, relative to drugs of abuse, the medications are released very slowly.
The exception can be if you use ADHD medications in ways they are not meant to be – such as snorting or injecting (neither of these are safe methods to use). By snorting/injecting, instead of digesting you get around the bodies need to digest, and you can get a sudden jolt of dopamine, which would potentially contribute to an addiction.
Dr. Travis Barron is a resident physician in Toronto, Canada.
Yesterday, in the language matters segment, we discussed what Obsessive-Compulsive Disorder is not. Why is this important? I find that a large driver of stigma against mental illness, is the emergence of medical and psychiatric language in common speech. When this language is used carelessly, a false image of a world where everyone has a mental illness can develop, and people become jaded to the topic. By discussing what mental illness is not, I’m hoping to dispel at least some of the myths and stigma surrounding the field.
OCD is real, and it’s debilitating – but it’s not all doom and gloom! OCD happens to be treatable, and the first step towards treatment is diagnosis. OCD happens to be one of the most underdiagnosed and missed psychiatric illnesses, so getting the diagnosis can be harder than you’d think.
Before we begin, I’ll reiterate a point from yesterday’s discussion – for it to be OCD, or any mental illness, there has to be a functional impact. In other words, if it doesn’t cause you a significant problem, it isn’t an illness! I’m not in the business of policing thoughts and behavior.
The four kinds of OCD
Mental illnesses are complex, and are extremely variable in their presentation. In a woman, depression often comes out as tearfulness. In a man, the same depression might cause uncontrollable anger. To aid in the diagnosis of mental illness, physicians and mental health professionals rely on patterns, or rules-of-thumb, to aid their clinical skills. People tend to fall into patterns, or groups, though this isn’t always the case. The following describes four common subgroups of OCD, but rest assured these descriptions will not perfectly capture everyone suffering from the illness.
Perhaps the most widely known manifestation of OCD is contamination fears. People with contamination-based OCD will have obsessional thoughts of contamination, meaning they are extremely preoccupied with the idea that germs, disease, or some contaminant substance, will spread through some form of contact. These fears can go both ways, meaning the individual may have fears they will become contaminated, as well as fears they will contaminate others. These thoughts can consume hours a day and make thinking about anything else near impossible. Importantly, these fears typically do not make sense to the person experiencing them. I person with an obsessional thought that they will develop cancer from touching doorknobs knows this doesn’t make a whole lot of sense. But alas, their brain obsesses over it. This kind of thought is called an egodystonic thought, meaning that the thought or belief is different from how you actually feel.
Contamination obsessions may manifest with compulsions. An important point here is that for a diagnosis of OCD, you do not need both obsessions or compulsions, just one or the other (both tend to be present but one or the other may go under-recognized). Examples of contamination compulsions may be wearing many layers of clothing and gloves, despite it being a warm day. People may have to wash their hands thirty times or more after touching food, just until it feels right.
Contamination-based OCD is not being a neat freak, though being too much of a neat freak can be a mental illness. What am I talking about? To be honest, it’s a difficult topic to relay in words, but essentially, it gets down to what is driving the neatness. If someone has true obsessions (best elicited by a physician in their office), they will probably be having a thought more akin to, “I’m going to get AIDS from these scattered papers,” than someone who is just very neat, who would be having a thought like, “I need the room to be clean otherwise I won’t be calm.” The very neat person is displaying cognitive rigidity, which can looks like OCD, but is distinctly different. Rigidity is more alike what we would call a personality trait.
Editor’s Note: Stay tuned for the remainder of, “The four kinds of OCD.”
Dr. Travis Barron is a resident physician in Toronto, Canada.
Obsessive-Compulsive Disorder is a mental illness characterized by obsessions, a specific type of thought that occurs over and over, and compulsions, repeated rituals or activities that typically relieve anxiety associated with obsessions. Now, before you realize that you definitely have thoughts that won’t go away, and self-diagnose yourself with OCD, you probably don’t. In fact, only about two and a half percent of the population (2.5%, or 5/200) in North America will experience true OCD at any point in their lifetime.
So what’s going on? Before we talk about what OCD is, lets talk about what OCD isn’t.
OCD is not rumination
“Ugh, I can’t believe he said that to me!”
“I know, what a dick.”
“I’ve been thinking about it all day… all I can see is his face…”
We’ve all been in an argument. A heated one. Probably with a relative. If you’re unlucky, maybe even a mother-in-law. These things are upsetting, and they’re part of life. But they also suck. It can be difficult, and is certainly common, to find yourself ruminating about a fight, a conflict, or other sources of stress like a work problem or a death in the family.
“Make sure you have the papers on her desk laid neatly.”
“What do you mean?”
“She’ll freak out, she likes everything neat, she’s so OCD.”
A feature of true OCD is how unmovable many of these behaviours seem to be at the surface. Someone with severe, untreated OCD may find themselves incapable of leaving the house without checking the stove one hundred and twenty nine times. They may find the alternative, leaving without doing this, intolerable. This is an example of a rigid behaviour.
There are other examples of rigidity, as described in the example above with the desk and the papers. If people have high standards, or are very anxious, they can often have similar intolerance towards certain aspects of their life being altered. For example, if you are a perfectionist, you may have intolerance towards a messy desk, and therefore be very rigid when it comes to desk tidiness. If you are very anxious, you may have to leave for work twenty minutes earlier than you have to, despite getting there thirty minutes early, every morning. You may find leaving later intolerable. This might even cause conflict with more laid-back loved ones.
OCD is kind of getting a song stuck in your head – forever.
If you’re lucky, it’s a song you like. All the same, it can be annoying to get a song stuck in your head. It’s also quite common.
Current psychiatric opinion supports that this phenomenon is similar, or maybe even the same, to many true obsessive thoughts. The main difference between getting a song stuck in your head and OCD? Impact and duration.
The single most important feature of OCD is that it causes a functional impairment. As a physician, I’m not in the business of judging you, your thoughts or your behaviours. When a behaviour begins to cause functional impact, and impair your quality of life, it becomes a disorder. True OCD also taks up a significant amount of time, which is in part how it causes a functional impact. Yes, “Hey Ya!” by Outkast is annoying, but getting it stuck in your head on July 1 is not the end of the world. True OCD, can be debilitating.
A twenty three year old female law student. She’s spends six hours, every evening, after a long day at the university, studying. She does this for weeks and finally writes her exams. She fails miserably, and it’s devastating. She comes into your office complaining of depression and you start to talk about the exams. “I couldn’t study everything, I never had time.” “How is that possible, you studied so much!” “I couldn’t get past the first chapter. Every time I read a paragraph, I freaked out and was worried I forgot it, so I had to repeat it over and over and over until I had it perfectly memorized.”
A eight year old boy is seen standing in the corner of the house before he leaves for school. His mom notices he’s muttering under his breath for a few minutes and finally he leaves for school. That night, before bed, she asks him about the muttering. He finally opens up. “Every time before I leave for school I have to say, ‘Mommy loves me,’ one hundred times before I go or you’ll die.”
A thirty year old man lives at home with his parents. He’s brought in to the psychiatric emergency by his father one evening. His father discloses that his son has been unwell and has been unable to wash or clean himself. He has an intense fear that his left index finger will cause AIDS, and has been unable to touch anything, or anyone with it. Including himself. He’s required his family to bathe him.
These are all examples of real people I have met – with their stories heavily altered, though the principles remain – with true OCD, functional impact is real. To be fair, these cases were pretty straight forward, and not everyone is so lucky OCD can go undiagnosed and missed for decades, resulting in real people having real suffering for unnecessary reasons.
Well, it depends. This person probably does not have OCD. When I hear a comment like this, I immediately suspect “OCD” is being substituted for “rigid behaviours,” due to the behaviour being fairly unusual for typical OCD. There are forms of OCD which focus on symmetry (stay tuned!), though I suspect this is not the case here, because the person is laughing about it. Remember, it’s only OCD if it’s significantly inhibiting your function!
Editor’s Note: Stay tuned for What to do about OCD, and The four kinds of OCD.
Dr. Travis Barron is a resident physician in Toronto, Canada.
“Excuse me,” you mutter as you push up the street. You look over your shoulder and see one of them speaking into a cell phone. You mutter under your breath and dive onto a close bus. He’s calling for reinforcements.
Salvation. You think you’ve escaped them. The bus doors shut close and the vehicle begins moving. That’s when you notice a man reaching into his pocket. He’s reaching for a gun.
You take out a knife you’ve been carrying to keep you safe, since these guys started chasing you a few months ago.
Stab him.
The voice is overpowering. You bring your arm forward and the blade sinks into the mans abdomen. The bus comes to a halt before people can even process what happens, and you make a bolt for it,
* * *
It’s a sunny day and you decide to head to the mall and meet some friends. You step out of your apartment and take a breath of fresh air. The bus soon pulls up and you step on. It’s a red light so the bus stays stopped for a little while with the doors open. You hear some commotion down the street and see a guy running.
“Oh great,” you mutter to yourself. These guys are never good company. And of course, he jumps onto the bus. You’re standing with your hands in your pocket and try and not make eye contact.
The guy gets off the bus. And your bleeding. You sink to the floor and everything goes black.
* * *
Psychosis is among the most debilitating of psychiatric illnesses. Psychosis sets in at an early age, and often rears its head in resistance to many of our best treatments.
But was is psychosis?
In broad strokes, psychosis can be defined as a severe abnormality in perception. These abnormalities can come in two forms. Delusions are fixed, false beliefs that are inappropriate in a given context. Hallucinations are sensory experiences unique to an individual not otherwise experienced by others. Psychosis is also accompanied by cognitive symptoms, which can include problems thinking, disorganization of thought, and disorganization of behaviour. Finally, negative symptoms may also occur, such as flattened emotional response, and troubles with motivation.
It sounds nice on paper. In reality, individuals with psychosis experience a different subjective reality than most. And that’s OK. Usually. I don’t see much difference in believing you have microchips in your back than believing there are God’s in the sky. As a physician, it isn’t my job to tell you what to believe.
Many people with psychosis experience it pleasantly. They hear voices that others do not, which do not bother them. They see connections in the world that I can’t begin to compute and they love it. Sometimes, and not unusually, psychosis can be unpleasant. It can be depressing. It can be downright terrifying. It is at these points, that danger occurs.
As you can see in the scenario above, these are times we have to intervene.
Scared people act in self defense. This is true whether you have psychosis or not. When you have psychosis, you may suffer from a delusion of persecution. In other words, this would be the belief that people are after you. In the scenario above, the first person believes they’re being followed. They run up the street, they dive onto a bus and even have been carrying a knife. Finally, they commit an act of violence, and stab the person in the second scenario. Not out of malicious intent, but out of a true belief of self defense. To the second person, they were simply standing on the bus.
Even more worrisome can be command hallucinations. These are a form of auditory hallucination, or “voice,” that a person hears. These voices give orders or commands to a person, and often times, the person feels compelled to listen. This can be entirely “out of their control.” In the first scenario above, the person experiences a form of command hallucination, and this plays a role in causing them to stab the second person.
So is person one responsible for the murder?
Yes.
But this doesn’t mean they are criminally responsible.
Every few months, it appears. The latest headline and protest, lauding complaints that the most vile among us have been completely exonerated for their heinous crimes. “Not criminally responsible.” The uproar is usually dramatic. The disgust even more. From my seat, I simply try and waft away the stench of ignorance, and hope that some understanding will finally come from the news story of the day.
That time of the year has arrived again, as featured here, You can thank Joe Warmington
for inspiring today’s blog post, so let’s set the record straight.
What is Not Criminally Responsible (NCR)?
The easiest way to explain NCR, is to explain what it isn’t. It is not a complete and total exoneration (sorry Donald Trump). It is not a get out of jail free card. And it is not a failure of the justice system.
When someone is found NCR, they are basically found to be guilty of their crimes, but because of their illness. Presumably, someone who commits a crime and who is found NCR would not commit a crime while well.
Why does it matter?
The NCR system is designed to get people well, so that they can exit the system, and begin reclaiming their life. From a sociological perspective, they begin, “contributing,” to society again. To achieve this, a finding of NCR allows the courts the compel you to take physician prescribed medications, and to comply with any drug safety monitoring required. You are typically detained in a high security psychiatric hospital, and given limited benefits, only titrated along with medication effect. Ideally, with the proper treatment, you achieve remission.
So how long does an NCR last? Well, that depends. And the system isn’t perfect. Unlike the traditional justice system, NCR findings typically do not carry sentences. To be released from an NCR, you need to have the approval of a board (here in Ontario, the Ontario Review Board), to be released. For them to be satisfied, your symptoms typically have to achieve remission. This can take a wildly different amount of time for different individuals, since everyone’s condition responds uniquely. The detention typically lasts years, followed by a step-down outpatient monitoring system. Eventually, you achieve an absolute discharge, and you have no more restrictions than your average citizen.
Like I said the system isn’t perfect. Vincent Li was infamously discharged after only nine years, following a gruesome bus beheading. Anecdotally, I’ve heard of NCR findings for robberies lasting decades longer than a regular robbery sentence. At the end of the day, the system usually works, and does a fairly good job at balancing victims rights, with human rights, and acknowledging the terrible impact these life changing illnesses may have on not only the ill individual, but all of us.
And it could use some tweaks.
Editor’s note: The focus of this post was NCR findings, therefore I focused on the risk of violence in cases of psychosis. Violence remains very rare in people with psychosis. Much more commonly, psychosis puts a person’s own safety at risk, through an overwhelming desire to complete suicide, and through personal neglect.
Dr. Travis Barron is a resident physician in Toronto, Canada.
My greetings will eventually sound less lame! I hope you have been enjoying mindMD and I truly hope it’s provided some help or hope for even just one of you out there.
Man, am I busy!
As you can read here, I’ve recently jumped into a new residency program and it can take some time to get your bearings. I’m sure you’ve all been in similar situations.
What does that mean for mindMD? Lots of awesome, cool topics, as they relate to medicine as a whole, with a special eye for the psychiatric and psychological interplay with physical health.
It also meas a brief slow down, for now.
Don’t worry, I’ll still be posting! For the next month or so, you can anticipate three or four posts a week.
In the meantime, you could help me, by sharing this blog with your friends if you like it! I stay as far away from social media as humanly possible in this day and age, so any Facebook or instagram exposure you can offer is greatly appreciated,
Until next time!
DTB
“That thing around my neck is called a stetho-something” – me
Depending who you’re asking, you might not always get the same answer.
I had just begun working at a psychiatric hospital in Ontario when this quirky word suddenly became part of my vocabulary – client. I had met countless patients before but these clients, it would seem, represented a new hurdle. What is a client? What do they want? Do they like the Raptors? Do they drink water?
Well as I would come to learn, clients are not so different from patients. Clients breath air, live in cities, and walk among us. They suffer from depression, anxiety, mania, and psychosis. They have addictions.
Medicine is rooted in a millennia of traditions. Some of the principles of medicine still used today date back as far as the Ancient Greeks. Hippocrates, and the Hippocratic oath, remain a quasi-initiation at the front end of most medical schools. Leonardo DaVinci, and his drawings of the human body, can be considered to still have an impact on the field of medicine today.
With all history, we tend to focus on the highlights, and leave the dark corners undiscussed and ignored.
Paternalism is part of medicine’s darkest legacy. What is paternalism? Here’s a long, winded answer.
In broad strokes, medicine is super #$%&ing complicated. No doctor understands all of medicine perfectly, and we certainly don’t expect a patient/client to understand all, most, or even some, of medicine. As a physician, my job is to explain the relevant information to you, so that you can make your own decisions. I have the responsibility to give you the required information, and to ensure that whatever I do, is in your best interests. This results in something called a fiduciary relationship, meaning that if you need a test ordered, it is on me to order that test, even if it’s seven o’clock in the evening on a Friday and the Blue Jays are about to take their first swing. Fiduciary relationships are a great and essential part of medicine. I reiterate my comments on just how complex medicine is! However, there are also some unwanted side effects.
As a doctor, if you are under my care, as we would say in the field, I am taking ownership of your care. This doesn’t mean I own you or your property, but basically that I am the captain steering the boat that is your health into harbour. Ownership in many ways is how things get done in medicine. If nobody feels responsible, than who would make sure your x-ray was ordered or that the proper consultations had been made, after all. Like all captains, we have a natural aversion to back seat drivers. “I know how to lay the anchor, so bug off!” kind of deal. We can even start feeling this way when the patient has different opinions from our own. Sometimes, we can even have a natural tendency to dismiss a patient’s thoughts when they conflict with our own. This would be paternalism, or in other words, a medical care model where the doctor’s wishes are given the highest priority, although presumably to save your life (whether or not you want your life saved – a whole other discussion there).
In another time, only decades ago, you might find that this is actually how medicine was practiced. What the doctor says goes. Forced sterilization and lobotomy being some more infamous examples. Today, we know better.
You are the captain, and I am the first mate. I help you navigate, but it’s up to you to steer. As a physician, it’s my job to listen to your concerns and give them thoughtful reflection, no matter how they may conflict with my own thoughts. This doesn’t mean ordering unsafe medications or needless tests, but giving an honest, thoughtful, patient-centred approach to care in all respects. This is the opposite of paternalistic medicine.
So what does this have to do with the whole patient/client conundrum?
Patient is a physician-born word. It’s language we have always used to describe those we care for and it’s comfortable. But some people take offense to that word, and that’s OK. This is particularly important in psychiatry. The reasons for this? They’re many and complex, the stigma associated with being a “mental health patient,” born out of 20th century mass media being the most surface-level example. In psychiatry, the word “client” carries particular meaning, and has more voluntary connotations than “patient” can sometimes imply, given the history of (at times necessary) coercive treatment in psychiatry. The point is not every “patient” likes the word, and they have a right to not be addressed that way. Mental illnesses are to many, after all, not considered illnesses, and people would prefer to describe their experiences as something akin to psychological distress.
At the hospital I worked at in Ontario, the alternative term adopted by the institution was ultimately “client.” (As a side note, we borrowed this word from out psychologist colleagues!) They chose to institute an institution-wide movement to address every single patient as a client. As you can see from reading this blog, I obviously don’t do that. But I also do not call everyone a patient. The reality is, I am more comfortable with the word patient and it’s been what I’ve always used. But the moment my client or patient or glerblegerker let’s me know that they disagree with the idea of being a patient, I’m quick to change my language with them. It’s about them, after all.
So you tell me – are you a patient or a client?
Editor’s note: Mental illnesses are true illnesses from my perspective, but not because of any of the particular symptoms you have – hear and chat with the voices in the empty room all you want. To me, your experience is an illness when it begins to interfere with your functioning and safety.
Dr. Travis Barron is a resident physician in Toronto, Canada.
It’s a Friday night in 1975. You decide to hit up the cinema and see the latest Jack Nicholson flick that’s been pegged as Absolutely Maddening! One Flew Over the Cuckoo’s Nest, based on the 1962 book written by Ken Kesey, went on to become one of the most popular and absolutely terrifying psychological thrillers of it’s time.
It’s also caused significant damage to the field of psychiatry that remains felt today.
Credit: One Flew Over the Cuckoo’s Nest
There are a number of disconcerting features of the movie, with inpatients being locked in straight jackets and handcuffs serving as just one example (this never actually happened except in certain cases of very dangerous, high-risk people, which I agree is still inhumane; it’s not practiced whatsoever any longer). One of the most significant and gruesome scenes featured in the movie is a scene featuring electrocompulsive therapy (ECT).
The main character Randle McMurphy is played by Jack Nicholson. In the scene, Nicholson is brought into a room by security, and is met by another twelve men, who proceed to man-handle him onto a stretcher. They paint him with “conductive,” and shove a mouth guard in his mouth. They proceed to shock him, featuring loud screams, huge convulsions, and best of all, all while he is still completely awake. Gruesome. But come on.
ECT remains a procedure of mystery in the public realm and sadly that has resulted in people disproportionately and incorrectly being informed on the nature of ECT by modern media. In the 1970’s, at a time when media was limited to movies, and television, productions like One Flew Over had a tremendous impact that still hurts the field of psychiatry, and most importantly, patients.
“My recommendation is a short course of elctrocompulsive therapy, also known as ECT.”
“No, no way I want that. I don’t want to be electrocuted man.”
“In my experience, ECT is the treatment that would work best for your condition.”
“There’s no God damn way.”
ECT remains today one of the most under-utilized therapies in medicine. That’s because ECT actually has a tremendous amount of evidence for a number of different psychiatric disorders, and in many cases, works significantly better than medications. Yet due to patient and provider stigma, ECT is often left aside because people “don’t feel comfortable” with it. Movies like One Flew Over popularized what can only be described as torture in the movie, and called it ECT, which is actually an extremely safe and effective procedure.
What are some advantages of ECT?
Electrocompulsive therapy is unique in it’s ability to treat a number of different illnesses. I have routinely used ECT to treat depression, depression with psychosis, mania, and behavioural/psychiatric symptoms of dementia.
ECT is the most effective treatment for unipolar depression (also known as Major Depressive Disorder). Remission rates have been estimated as high as 90%.
ECT is the most effective treatment for bipolar depression and mania. Remission rates have been recorded as high as 80%.
ECT, in many cases, works more quickly than medications.
ECT is safe in pregnancy whereas many psychiatric medications for bipolar disorder are not.
No medication side effects.
ECT is performed under anaesthetic.
ECT is performed with muscle relaxants; usually, the only convulsion seen happens in the big toe.
ECT is one of the only treatments approved for suicidality.
What are some disadvantages of ECT?
ECT requires a hospital, an anaesthesiologist, and a psychiatrist to administer. This costs money and resources (arguably, the cost saved by the quick and larger effect mitigates this).
ECT does have some side effects, most notoriously memory and thinking problems on the day of the treatments (a typical course involves three treatments a week for a month, and then tapering that down).
ECT can require maintenance treatments once a month for a few years or longer after you complete the acute course.
The conclusion? ECT remains one of the most effective and safest treatments in medicine. It has the ability to help people, and I’ve seen it. What’s inhumane is how little access there is to this treatment around the country.
Editor’s note: Working in Toronto, ECT was a relatively accessible service. I’ve worked at three hospitals, at least, with the ability to do ECT. This is not the case everywhere. I’ve worked in centres acorss the country where there is no access to ECT, and sick, unwell people, who deserve to have this excellent treatment, are left to go and suffer without. Improving ECT access and education is part of ending the stigma!
Stay tuned for “How does ECT work?”
Dr. Travis Barron is a resident physician in Toronto, Canada.
It’s mid-July, and that means vacation. You’ve been waiting for this all year. You can’t wait to have a few weeks to just sit, relax, maybe take in a few books. And don’t forget the wine.
You arrive home and see your husband. He’s beaming as he gets off the phone. You kiss him hello and for a moment, everything is still.
“I don’t know, you bought good steaks for the weekend?”
“Well also that, but something else… my mother is coming to stay with us for a week!”
The calm serenity melts out of your hands and you instantly feel tight. Your muscles start to ache and your teeth are grinding. You notice your heart rate is picking up as your husband asks, “are you OK honey?”
It’s an uncomfortable feeling.
I think we can see why our fictional character may be anxious in this case. A surprise visit by the in-laws on her vacation. Yikes! (If you’re reading this my in-laws, totally love you guys!)
So she’s anxious – but why does anxiety make us feel this way?
Like I’ve spoken about time and time again, anxiety is not a mental illness. It is a personality trait. Like all personality traits, anxiety can both serve us and hurt us. Anxiety makes us not forget our wives’ birthdays, and makes us turn off the stove. On the other end, anxiety can be the root of some mental illnesses, such as Generalized Anxiety Disorder.
Anxiety originally involved in humans as part of the adrenaline nervous system, called the sympathetic nervous system. It’s function? To help us stay safe in the jungle, and to help us fight off a predator – but doesn’t help us do much about it. Fortunately for us, we have evolved a way around this. As I’ve discussed previously, the brain operates through it’s connections, and those connections exist in very complicated but specific ways. This means the brain likes patterns. Anxiety is no exception. The anxious nervous system directly connects to the adrenaline nervous system, and turns it on when we are feeling anxious. What does the adrenaline nervous system do? Well it’s also called the fight-or-flight nervous system. This nervous system prepares our bodies and allows us to either fight off a predator such as a boar, or flight/run like crazy from something like a tiger. To allow us to do these things, the adrenaline system dilates our pupils, to improve our vision in the dark. It raises our heart rate and blood pressure to get blood to our organs and muscles, and tightens our muscles, in anticipation of a great battle or a long sprint. It freezes our digestion to preserve resources. The benefits of this connection-based system are obvious when we examine someone like a caveman.
Not so much with anxiety.
The brain doesn’t always distinguish one situation entirely from another, a symptom of it’s pattern-based operation. These same connections are activated when anxiety is caused by a seemingly harmless threat, such as news your in-laws are visiting. Increased heart rate and blood pressure can feel overwhelming and make it impossible to sleep. Muscle tightness turns into uncomfortable chronic tension. Frozen digestion becomes abdominal pain.
But there’s an end. As these things go, the physical symptoms of anxiety typically burn out over the course of a few hours. There may always be more mild chronic symptoms in the background but in general, anxious people are not always in relative crisis. Funny enough, the duration of the average panic attack (about fifteen minutes) last about as long as our adrenaline stores last.
And we can retrain these connections. Through cognitive behaviour therapy (CBT) you and a therapist work together to identify the thinking patterns that lead to a number of mental illnesses, including anxiety. Once you identify those patterns you can begin to change them, and “train” your brain to not always turn on your fight-and-flight response, at least so intensely, when you feel anxious.
Dr. Travis Barron is a resident physician in Toronto, Canada.
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