Mental illness exists for a reason (part 4)

Thanks for reading and keeping up with this series – Mental illness exists for a reason! In part 1, part 2, and part 3, we discussed the evidence for genetic control of behaviour in primates, and found that variability within a species’ genome allows that species to be adaptable. Humans are an example of a species with a variation in genes within  their genome, allowing us to become one of the most successful species on the planet! We discussed that because of this variability, some of us succeed in cities, rural areas, at high elevations, or thrive working underground. It also means that not all of us will succeed – at least in every environment.

So how do we guide treatment and recovery, with this understanding of mental illness?

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When I was in grade school, as there tends to be, there was always the one problem child. Teachers would scorn this child, parents would be caught whispering about the kid in hushed after-dinner conversations as they dispersed the latest rumors coming from the school. This child had bad grades, would act out in class, and was the regular example of how not to act when your parents warned you about the repercussions not studying. “Do you want to end up like Johnny? No future?!” You could say that in the eyes of the masses, this child was struggling.

Johnny felt he was struggling too. He didn’t seem to jive with the classroom environment. He had a lot of pent-up energy he felt he had nothing to do with. He intended well, but ultimately was ambivalent regarding his grades. ‘What will I ever need that for, anyway?”

I eventually moved on from grade school, and high school, and university, and medical school. Years later, on a short trip home to Newfoundland, I saw Johnny in the supermarket, He was with his beautiful family, and had three kids. We got to talking and it turned out he entered trade school after high school, was at work a few years later, and now actually owned a home. The thing that stuck out the most was he was glowing. Absolutely glowing., I couldn’t help but feel, this guys got it all figured out.

But Johnny was struggling. So what happened?

Not everybody will thrive everywhere. I could think of lots of examples from my office, but I thought that this example was more down to earth and a great example of how things are not always as they seem.

Johnny was never meant to sit in a classroom, and was intended to use his hands. When given the wide open expanse of a work day and a welders hat, he found his niche, and owned it. The reality is, the filtration system this is our school system didn’t work for him, and he struggled.

The conclusion? Sometimes, a change in environment is the most important intervention when you are struggling with a mental illness. If you live away from your family and friends, and are struggling, my pill will have limited benefit. Until jobs can stop requiring people to work 50, 60 hours a week for next-to=nothing, people will suffer.

Editor’s note: As if it wasn’t complicated enough, I’ll add an asterisk! Often times, when you are in the throes of a mental illness, your judgement can be distorted. In general, I recommend people do not make life-altering decisions while severely unwell. A discussion with your doctor on how to best approach this scenario is my recommendation.

Not all mental illness is a result of person-environment incompatibility. There are true, organic mental illnesses out there. Often times, a combination of medication, therapy, and life changes, is required.

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of parts 1-3 of this blog series.

Dr. Travis Barron is a resident physician 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.