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.

Living on the edge

Bzzzzzzzzzt.

“Hi there! You have been randomly selected as a winner of our draw! All we need is your credit card number-”

“For fuck sakes.”

Have you ever answered a robocall at four in the morning? You hear the ungodly buzzing of your device – turned on vibrate, so as “not to wake anyone” – and you’re sure it must be a family member in crisis, or a work email that can’t be missed. Instead, you are greeted by the disorienting sound of a fog horn and the robotic voice of the latest phishing scam as they tell you, “the Captain’s calling!,” and start wooing you with free cruise trips, with one catch. They need your social insurance number.

Fat chance.

The next day, you’re at work. You laugh with your colleagues about the Captain, and you realize the same thing happened to all of them as well, at some point. There’s a certain comradery in the shared psychological torture. That night you can’t get to sleep, and you wonder, “why am I so damn restless?!”

Hopefully, this exact scenario hasn’t happened to you, but I’d be willing to bet you have answered a phone call in bed at all sorts of hours in the morning. It’s a habit many (and probably most) of us do in our technologically driven society. While most of us realize that getting up numerous times a night isn’t allowing for the most restful sleep, many people often do not realize the deeper psychological consequences of bad phone hygiene.

In broad strokes, anxiety can be defined as a, “fear of uncertainty.” Which makes sense. Anxiety can be accompanied by several symptoms – concentration difficulties, fatigue, irritability, restlessness, and muscle tension. These symptoms are caused by an increase in the part of our nervous system that controls adrenaline, called our sympathetic nervous system. This is the part of the nervous system that allows us to react to uncertainty. In prehistoric times, the benefit from these functions is obvious. You want to be angry, on edge, and have tight muscles (and definitely do not want to be asleep) when the sabretooth tiger is attacking you. Today, these symptoms often cause us discomfort.

Smart phones are wonderful things. They allow access to hordes of information at any given time, and have allowed us to connect with each other on an unprecedented level. They have also allowed us to, unlike ever before, take work home to an entirely different degree. The expectation in many offices today is that emails should be answered immediately, regardless of the time of day (and even if you’re on vacation). In other words, smart phones, while wonderful, represent the endless possibility of something significant happening – a family death, a big deal, the Captain – at any given time, which requires our response. And we sleep with it. Ew.

Our smart phone addiction has contributed to a baseline feeling of uncertainty that in many of us turns on the adrenaline nervous system, and causes us the symptoms of anxiety. Bad phone hygiene, such as sleeping with your phone, and not setting limits insofar as when you will answer your phone, contributes greatly to the symptoms of anxiety, not just on the night of that inappropriate call, but for many nights to come.

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

One hundred diagnoses

“You have depression.”

“I think it may be bipolar disorder.”

“Borderline Personality is most likely.”

“Have you ever heard of Posttraumatic Stress Disorder?”

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You’ve been feeling down lately and you decide to see your doctor. They might refer you to a psychiatrist, or choose to diagnose you themselves. You might do this several times over your lifetime, and each time, you get a different answer. You go, “what the fuck?”

It’s a common conundrum.

In psychiatry, we do not have the luxury of many of the tests and tools used by other fields of medicine. In other words, we don’t have the luxury of x-rays and blood tests to aid in the diagnosis of the vast majority of illnesses we work with. What does that mean? As psychiatrists, we rely primarily on our clinical expertise, the histories provided by individuals and their families, mental status exams, and whatever collateral information is available to come to our conclusions.

After we have gathered all of the available information we arrive at a hypothesis, or best guess – don’t worry. We’re usually right! Psychiatric diagnosis is a finicky thing, because I’d be lying to you if I said I, or any other physician, had the ability to understand perfectly the inner workings of your mind and your own personal experience in an hour-long conversation. The point is, people are complicated, and what may appear as depression one day may come to reveal itself as posttraumatic stress disorder on another.

So what’s the point of seeing somebody, if their diagnosis may be fluid? We can help. Working with a mental health professional at times of difficulty can be an important resource, especially when in a publicly funded healthcare system such as Canada’s. Even if your diagnosis may evolve over time, our treatments are often (and usually) pointed in the right direction. The treatment for depression and anxiety are often the same, and the same is true for bipolar disorder and schizophrenia. Most importantly, regularly seeing a physician can be a rock during times of turbulence, and I would recommend that to anyone, regardless of diagnosis.

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