All the different kinds of mind reading – does it exist?

The ability to read minds is a superpower often portrayed in many forms of popular media. The idea of being able to understand our peers, down to the most minute detail, is both seductive and a credence to our innate desire to understand one another. It is our perception, of the understanding of others’ minds, that we use to shape our views of the world. Mount Rushmore, in the United States, for example, only holds meaning because of our collected understanding of the grandeur of the monument, and an appreciation of what/who we gaze upon.

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All humans sort of read minds – it’s called intuition. Based on the feelings, actions and behaviours of another person, someone with well practiced intuition can often tell when something is wrong, or when someone is excited. Believe it or not, these functions are encoded directly into our brain, in an area called the posterior superior temporal sulcus, an area dedicated to recognizing facial expression. The ability “read ones feelings” is so integral to our survival as a social species in fact, that many animals exhibit this level of intuition, dogs being the most obvious example. Have you ever had your pet dog come and comfort you on a difficult day? Ever have your German Shepherd start barking at a stranger when you start to look alarmed and panicked? Ultimately, this phenomenon comes from a profound ability to react to subtle nonverbal communication, like facial expression and body position, on a seconds’ notice.

People have different degrees of intuition. For some people, they are able to “read a room” without ever having met anyone in it. For others, they have a difficult time guessing a loved ones’ thoughts, despite their best effort. There are likely genetic and environmental reasons for this, although they are not well-defined.

Someone practicing as a psychic shows a high level of human intuition and understanding of the human experience, for example. By reading your face, body language, reaction to their readings, and with a little context, they are often able to provide spookily relevant advice to you about, for example, the death of a loved one.

Anxiety and mind reading

A psychic is a great example of a person using an innate ability to their advantage for their profession. Not always, however, does strong intuition on the feelings of others provide us an advantage. Many people with an anxious disposition find themselves hyper-aware of situations, and consequently, it can become overwhelming. Seeing a young group of teenagers for example might set off the anxious persons “spidey sense” and prevent them from walking by the group, whereas someone else may find themselves less preoccupied by this group of people.

An anxious person may also find themselves taking too much responsibility for keeping the flow or a party, group, or conversation comfortable, because they are more sensitive to the various social cues sent out by the attendees. An anxious person would be the first to recognize when Tim was getting bored or when Siobhan is feeling uncomfortable. They might be the first to recognize when dad has had too much, or when the hostess is getting tired. Obviously, having some degree of this behaviour shows high social intelligence. If you find yourself being unable to enjoy your own birthday party for the same reason, it might fall under the umbrella of a disorder.

Cognitive mind reading and depression

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“Everyone hates me.”

“My friends think I’m boring.”

“I know everyone is looking at the weight I put on when I go to work.”

“I give a bad first impression.”

“They all think my clothes is lame.”

One of the most common forms of pathological mind reading, is cognitive mind reading. See the examples above. We have all, probably, had a thought at least something like that at some point in the past. We might even be having those thoughts now.

The above examples represent cognitive mind reading, a phenomenon common to many forms of depression. Cognitive mind reading involves someone often making a negative assumption about someone’s thoughts, as it relates to themselves, out of keeping with reality. “Everyone hates me,” for example. Everyone does not hate you. Most people on the street don’t know you! These thoughts are actually a reflection of a depressive process.

When you become depressed, you put on some “gray-coloured glasses.” What this means is you often view things in a more negative light. The skies are grayer, video games are less fun. And seem esteem deflates. The social intuition discussed at the beginning of this post is no exception. When you’re depressed, this part pf your brain becomes hijacked, and all of a sudden, you may find yourself thinking that the world is thinking a lot more negative of you, even though it isn’t. In reality, those negative mind reading assumptions (where you believe that all of the negative things you worry people are saying about you are true) are a reflection of your brain being depressed. When you’re depressed, your brain colours everything gray. It sucks!

But it’s not all doom and gloom. Cognitive mind reading is one of the most common forms of cognitive distortions seen in depression, and physicians and therapists are well positioned to help you handle this. One of the first steps to this is understanding what cognitive mind reading is, why it’s happening, and importantly, that it’s very common in situations like your own. You’re not going crazy.

And not everybody hates your jacket.

Thought reading

While cognitive mind reading is extraordinarily common, with many depressed and non-depressed people experiencing some degree of this on any given day, thought reading is relatively rare.

Thought reading is a delusion, and is actually one of the more classic features of a

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psychotic (not psychic) illness called schizophrenia. When someone is experiencing thought reading, they literally believe that they are privy to the thoughts of others. I can literally hear your thoughts. This can be differentiated from cognitive mind reading in a few different ways.

Someone with thought reading may (though not necessarily) literally hear the thoughts as a form of auditory hallucination.
When you ask someone with cognitive mind reading to explain how they know “Yousef hates me,” they will usually give a lot of evidence, as if building an overwhelming court case. “Look at the way he did this… look at this behaviour… and I just know he does because this… he hugged me last and it seemed uncomfortable…” Someone experiencing thought reading will often reply, “I can hear their thoughts.”
The clinical picture is wildly different in both (though there are of course borderline cases). Thought reading is accompanied by psychosis. Cognitive mind reading is accompanied by anxiety and depression.

An important note here is that cognitive mind reading usually upsets the person and causes them problems. Thought reading has a variety of much more extreme reactions attached to it.

A twenty two year old male presents to the unit acutely psychotic and paranoid. During the course of the admission, he is very aggressive, and damages much of the furniture on the wards in a psychotically driven rage. When he’s better treated, you speak to him, and he discussed that he read the thoughts of the female nurses, and they all thought he was disgusting, which angered him.

A thirty year old male tells you about the microchip he had implanted so he can now read minds. He plans to kick some ass on the stock market with this new information. You diagnose him with a grandiose delusion.

If you are worried you have some form of mind reading, it’s most likely some degree of cognitive mind reading. If you’re concerned, see your doctor. They might help!

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

What it’s like living as a doctor under the (Toronto) poverty line

“Hey, would you like to come catch some lunch with us? There’s this new Mexican place around the corner.”

“No thank you, I have a lot of work to do, I’m going to stay here and catch up on some documentation, next time though!”

“Alright, have a good lunch.”

I quietly closed my office door and flushed pink with embarrassment. I hope that was convincing. I reached for my battered book-bag, and pulled out the two slices of toast and the bag of almonds I had laying around the apartment that morning. My chopped up frozen peas and corn were still frozen.

It tasted a little like cardboard, but it was OK. As I sat eating, I couldn’t help but think about other social events I had to come up with some elaborate excuse to avoid, because I was broke. Beyond broke. I recalled the Tim Horton’s server earlier that week, who stood by annoyed as she counted out my forty nickles – or I thought it was forty. I was five cents short; luckily the annoyed customer behind me overheard and threw a dime down on the table, a little in kindness, but also to help get the line moving, I thought.

That was three days ago. I haven’t been able to afford a coffee all week.

It gets more difficult some days, particularly when tempted with succulent chicken polo frito I know I can’t have. I looked down at my jeans, which I had worn every day this week. They looked shabby and I saw a small yellow dot of something – mustard? – on one pocket. I tried to brush the spot off but it only smeared the yellow-goo deeper into the fabric. I felt the seam of the jeans, gently rubbing the pale, white thread I could tell was going to give out, at some point. Hopefully they last until my birthday… I only owned two pairs of pants that fit me you see, and one was in the wash.

And the drier was broke.

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This scene may seem vivid, I hope it is. These events don’t begin to touch on the poverty many residents of the world, country, and Toronto face on a daily basis. I have a relatively safe apartment in a decent neighbourhood, and most months I can afford to get a transit pass.

This story is also about me, and it’s not where I expected to end up as a doctor. So what gives?

For those of you who have read this blog for some time, you will know that I am something called a resident physician. Residents are kind of primordial doctors, having finished medical school, and now completing a program in the specialized area of medicine they will eventually work in for the rest of their life.

Becoming a resident, and a doctor, takes many things. It takes academic rigour, professionalism, dedication, and mental toughness. It also takes a tremendous amount of money.

To enter medical school, you need an undergraduate degree. For most people in Canada, those degrees, four years in duration, can cost anywhere from $10 000 to $50 000, depending on the school you attend. Most young people in Canada don’t have this kind of money just sitting around, and ultimately the vast majority of university students depend on one of two sources of funding – student loans, or help from their parents. Leaving conversations about how the education system is designed to discriminate against the poor aside, I’ll mention here that I was one of the more fortunate undergraduate students at Memorial University, and only graduated with about $15 000 in student loan debt.

In the fourth year of my BSc (Hons) in Cell and Molecular Biology, I began applying to medical schools – at about $700/$800 per application. Those of you who know anything about medical school admissions knows that you don’t want to “hang your hat” on one school, it’s not unlike the lottery. Keeping this in mind, I ultimately opted to apply to seven medical schools, which stung my pockets, but felt necessary at the time.

I was ultimately offered two interviews, one of them here in Ontario, and after some reflection and my acceptance, I found out I was going to medical school! In Windsor, Ontario.

Most Canadians mistakenly associate things like $25 000 a year education to places like the United States. Not so, for medical school. I was dismayed to realize my tuition would be that, and more per year, considering the various $1000 “enrollment fees” and the “one time $800 course fees,” for the odd mandatory skill seminar put off by the school. I did the math, and yes, this was going to cost me $100 000. And I was going to pay interest on that money, as well as my $15 000 student loan, every single day, until the time I graduate. (As an additional fuck-you from my medical school, they went on to increase the cost of tuition every single year I was in medical school; my fourth year, initially supposed to be $21 000, the cheapest year since it was essentially six-months in duration, costed $26 000 by the time for me to pay).

Now of course, as anyone with student loans will attest to, the cost of education is hell of a lot more than tuition. There are textbook costs, transit passes, rent, groceries. All of these things costed money, and since I was going to school 3000 km away from my nearest relative, I had nobody to lean on.

It’s here my trajectory deflected from my colleagues. You see, not everyone enters medical school as equals. The vast majority of my colleagues received significant financial help during medical school from their families. Most people in medicine you see, have doctors for parents, many have a trust fund. A quick Google search can shed light on the tremendous problems of socieoeconomic skewing in medical school classes – it seems like hiring and accepting people from penthouse suites doesn’t increase physician availability in the projects (no s*** guys I could have told you that)!

This is also the case in all education programs, where some students have it better than others, but when you’re surrounded by people without student loans, travelling across the world on the odd weekend, you feel it a bit more. Everything I paid for in medical school was on my back, and it still is.

And I’ll be the first to admit it. I had housing costs, groceries, living expenses. I also enjoyed myself during medical school, not excessively, but in an effort to feel like a part of my class. It was difficult, living in Ontario, and being the only person not travelling to Europe over the summer. It hurt wearing shabby mall-bought clothes among my peers when most of them shopped at expensive outlets.

I eventually finished medical school, and it was finally time for a pay day.

I also fell in love.

I ended up being accepted into a residency program at the University of Toronto, and I moved to the city to be with my partner. She had just finished a different academic program herself, and we had very little money. We accepted the cheapest apartment we could find that had access to the subway. You see, with both my partner and myself working in health care, we worked 12 hour days, if not longer, and a two-hour-each-direction transit ride was not an option. We found something that was a 45 minute transit ride away from our work, 700sqft, at $1800 a month. Yes, that’s obscene. It’s also the reality in Toronto.

The Canada Mortgage and Housing Corporation estimates that housing becomes “unaffordable” when it takes up more than 30% of your income. Many people in Toronto are in an unaffordable housing situation, myself included. This rent costs about 52% of my income per month.

Now I know what you’re saying. “That’s not a lot of money for a doctor.” It is for a resident. My resident salary in Ontario is $58 000, before taxes.

And before my $1200 of student loan INTEREST payments a month (barf).

And before groceries.

And before cell phone.

And before my transit pass.

At the end of the day, it’s really not a whole lot of money. There’s often a month where I have no transit pass for the first few weeks, and I count dimes I have left around the house in hopes of getting on. A few times, I’ve had to sneak onto the bus. Often the bills go unpaid. Don’t ask me about my VISA.

All of that to say, I’m hurting, and a lot of young professionals in this country and city are as well. It’s atrocious that medical schools, or any school, can gouge you for money they know is going to sit on your student loans – I’ve paid enough interest to my bank at this point I could have almost paid off a quarter of my debt. It’s disgusting that the government of Ontario does not account for the school of residency when determining salary – you make the same in Thunder Bay, with a significantly lower cost of living, than you do in Toronto, the most expensive city in the country.

So what’s it like living like a doctor near the poverty line? Just ask me.

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It was happening again. These damn asthma attacks. My shortness of breath was getting worse, and I was bent over breathing to try and get a sufficient breath.

“I think I need to go to the hospital.”

An ambulance costed $75… I checked my Uber app – declined. “Please update payment method.” Fuck.

I got in the subway, wickedly coughing, and then transferred to a bus, which I took to the hospital. I was somewhat blue by the time I got there, and they admitted me right away. They prescribed some puffers, and told me to take my allergy pills.

The following day, I went to the pharmacy with my two puffer prescriptions. I left the allergy pills in the aisle – $15 for ten pills? Not happening.

“Alright, that will be $15.”

“I thought my insurance plan covered the drug costs?”

“It does, but for this medication, there’s a co-pay.”

“I’ll only take the one then.”

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

The four kinds of OCD – Intrusive thought predominant

From Part 1:

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.

Part 2

Part 3

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Intrusive thought predominant

“Hi Doctor, we have a consult for you,”

“Go ahead.”

“He is a 18 year old male with daily, intense suicidal ideation. We’ve placed him on a form 1 and he’s in the emergency waiting for you.”

***

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Early on in my career as a psychiatry resident, I met a young man, just graduated from high school at one of the hospitals I was working in. I was working in the Psychiatric Emergency Service (PES) at the time, and had been asked to see the man by an Emergency Medicine colleague.

As these things go, you don’t always get the most information. Really all I knew about this person was that he was eighteen, was going to university for engineering, and had daily, intense suicidal thoughts.

As I walked down the hallway to meet him, I considered a differential in my head. Could it be depression? Psychosis? Had a manic depressive fallen into my lap? Or a personality disorder, perhaps?

***

“Hi, my name is Dr. Barron, I’m one of the psychiatry residents.”

“Hi I’m Sam, nice to meet you.”

“Nice to meet you as well. My emergency medicine colleague asked me to speak with you, is that OK?”

“Yes of course.”

“Let’s start with your understanding of why you are here in hospital.”

***

We began speaking, and very quickly it became apparent that Sam was not depressed. He wasn’t psychotic. He definitely wan’t manic. I couldn’t even get a whiff of a personality disorder off of him. What the hell was going on?

I didn’t know it yet, but what I was seeing was a common manifestation of OCD, called intrusive thoughts. These thoughts are intense, and are very bothersome to the person. Some classic examples include:

Suicidal thoughts (killing yourself)
Violent thoughts (killing a random person or a family member)
Sexual thoughts (homosexual behaviours if you are heterosexual, heterosexual behaviours if you are homosexual, or pedophilia)
Blasphemous thoughts (against your own religion*)

An important point here is that blasphemous thoughts typically only occur when someone cares about being blasphemous i.e. it would not be considered a blasphemous thought to pee on a church if you didn’t care about peeing on churches.

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So wait. Suicidal thoughts can be intrusive? How is that different that a regular suicidal thought? Well, in intrusive thought predominant OCD, the thoughts are egodystonic, meaning they are in direct conflict with that persons values. In other words, a person with intrusive thought predominant OCD does not want to kill themselves, hurt someone, abuse a child, or disrespect a religion. In fact, they are often extremely disturbed by these thoughts.

Another important point to remember is that all forms of OCD have some level of intrusive thought based symptoms, however, the intrusive thoughts are not the predominant feature.

In contamination based OCD, intrusive thoughts of contamination cause extremely debilitating compulsions, focused around cleanliness, which tend to be the primary feature.
In doubt based OCD, compulsory checking tends to be the predominant feature.
In numeracy/symmetry based OCD, extreme cognitive rigidity and intolerance, as well as compulsions, tend to be the predominant feature.

***

“So doctor, what do you think is wrong with me?”

“Well, this sounds like OCD, a treatable illness. This doesn’t mean you have to kill yourself, or hurt anyone. These thoughts you are having don’t represent anything about who you are, or anything bad about you. In fact, the fact you’re so bothered by them shows how much you value human life. We’re going to help you.”

***

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.

Editor’s note: Read about what OCD isn’t!

Stay tuned for OCD – What to do about it.

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

The small things

“Thirty five!”

My heart begins to pound. Could it be? That’s three out of six numbers so far, I had never done this well.

“Seventeen!”

I’m out of the seat. I grasp the lottery ticket in my right hand tightly and stare at the TV. Images of yachts, parties, European vacations flash before me. The woman on the TV bends over and pulls the last number from the bin.

“Eleven!”

I’m screaming. Everyone’s screaming. We’re hugging, jumping crying in joy, when –

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BEEEEEEEEEEEEEEEEEEEEEEEEP

I role over as I bring myself from a foggy haze back to the planet Earth. I look to my side, expecting to see the brightness of the TV and the infinitely smiling lottery woman. Instead I’m met with a dark bedroom and the slightest hint of sunlight beginning to break through the bedroom window.

It was all a dream.

For a moment, I’m sad. I mourn my yacht. I mourn the Greek islands. I prepare to mourn for my would-have-been pet Tiger, when the hope begins to trickle into my mind.

It’s Saturday.

Oh, Saturday. The king of days, the glory of glory. We meet again. What have you brought me today? Is it a hike? An interesting play? The sweet nectar of shameless hedonism and laziness so that I may bathe myself in relaxation? Perhaps.

But first, there’s coffee.

Ah, coffee. I smell the sweet fumes, the pungency of the beans as they’re cracked over blade. I’m intoxicated with the idea. I climb out of bed and realize my mouth is watering. I sneak by my loved one and enter the kitchen, the regular opening scene to my Saturday-plays.

I grind the beans, turn on the machine, and wait patiently through the glug-glug. Soon, it’s ready. I sit on the step and drink from my chalice. I find myself wondering just how much of my blood is this very drink. For those moments, the world is still. As long as there’s blackness that sits in my cup, time is frozen, and it remains in good form until I take the final sip.

I find myself mourning the lottery once more. I look to my cup and smile to myself. What I really appreciate, are the small things.

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

Chest pain is in your head

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It’s a beautiful winter’s day in suburban Ontario and you’re shoveling snow. It’s the first snowfall of the year so you don’t absolutely hate the task at hand. Yet. You stop to breath in the beauti—-

BLAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR.

The snow plow is on you in seconds and quickly packs your hard-shoveled driveway back in. As you swear to yourself, you continue to shovel.

Suddenly, there’s chest pain. Your vision goes black in the corners and you grab for something. You stabilize yourself on the side of your home and take deep, laboured breaths. You manage to pull your cell phone from your pocket, and dial 911.

“Hello you’ve reached 911 what’s your emergency?”

“I think I’m having a heart attack.”

***

“I don’t get what you’re saying.”

“Let me start from the beginning. Everything checked out fine with your heart. Your rhythm is normal and there are no signs of a heart attack. I think the most likely explanation is a panic attack.”

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“So you’re saying it’s in my head? That’s ridiculous. How could you possibly know it’s not a heart attack?”

“Besides the fact that your blood tests and EKG were normal, sir, you are 28. You have no previous cardiac history, you don’t smoke, and your family history is insignificant. Taking all of this together, there is no likelihood that this is a heart attack.”

“So I’m going crazy?”

“I didn’t say that…”

Panic attacks are real, intense manifestations of anxiety. Features of panic attacks include chest pain, shortness of breath, tunnel vision, dizziness, sweating, anxiety, and a fear you are dying, just to name a few. Best of all, panic attacks can have a clear trigger (snakes, for example!), or culminate out of apparent nothingness. Panic attacks can be unpredictable and debilitating, and are definitely uncomfortable. To put the icing on the cake, panic attacks can often present like a heart attack. Your fear of dying just got a lot better, didn’t it?

One of the most common consultations I have seen in my office are individuals who have presented to hospital numerous times with non-cardiac chest pain. The consulting physicians are usually suspicious of panic attacks. These consultations often unfold in a similar fashion – the discussion around the patients understanding of what’s going on, a discussion of their mental health and personal lives, and inevitably, feedback.

To all of my doctor friends out there in the internet, here’s what not to say when you suspect someone is experiencing panic attacks:

“It’s all in your head.”

Medicine and psychiatry are a lot of things, the least of which is not, being a source of reassurance. By dismissing an individual’s symptoms as “in their head,” you have immediately invalidated that person and there’s little chance they will listen to anything else you have to say.

But panic attacks are in your head, and so is the chest pain. But this is also the case with true cardiac chest pain. What am I saying? Everything, including true heart attacks, are to some extent, in your head!

What the hell am I talking about?

In your body, there are a specialized type of nerve cell called neurons. Neurons are like wires that connect different parts of the body and allow parts of the body to communicate with each other. There are neurons that go from your brain to your muscles, for example, which send messages on how to move. There are neurons that go from our skin to out brain which tell our brain what we are feeling.

This is equally true in heart attacks.

When you are having a heart attack, blood is suddenly cut off from a part of the heart and damages the heart muscle. This causes chest pain. The neuron that goes from your heart to your brain sends a message to your brain that you are having chest pain. This is how you become aware of it. As is appropriate when you’re having a heart attack and experiencing chest pain, you then begin to feel anxious. This anxiety protects us and drives us to call an ambulance and seek help.

So what’s going on in a panic attack?

paha If you recall, neurons are like wires. Like wires, messages can pass down nerve bundles in both directions. Messages can be sent from the heart to the brain (as in a heart attack), or from the brain to the heart. In panic attacks, our brain “hijacks” our natural nerve circuitry and sends the message in the opposite direction (brain to heart). This causes the cycle (chest pain -> brain aware -> anxiety) to reverse (anxiety -> brain aware -> chest pain)!

The take home message? The chest pain in panic attacks is as real as the chest pain in a heart attack. The difference is that the pain in each scenario is driven by a different cause (heart damage vs anxiety).

Why do I find this is important to understand? In my experience, when people seek help for panic attacks, often times a patient and physician can get too caught up on whether the chest pain is “really” happening. It definitely is. But to understand and accept that your chest pain is real and is highly unlikely to be caused by heart damage, for all of the reasons listed in the opening dialogue of this post, is empowering and indespensible.

Editor’s note: This article is not a substitute for medical consultation! If you think you are having a heart attack, particularly if you carry risks factors, you should seek medical attention.

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

Does ADHD exist?

“Based on all of the information you have provided, the collateral information, and the report cards, I think the most likely explanation is Attention-Deficit/Hyperactivity Disorder, also known as ADHD.”

“The doctors tried to diagnose me with that when I was a kid, and now you want to medicate my kid? I don’t believe in ADHD, we’re getting out of here.”

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It’s not an uncommon scenario. A parent brings their struggling child into my office for an assessment. The child promptly runs into my office, and immediately begins playing with the toys laid in a bin by my desk. Mom continually redirects the kid, who for some reason, just can’t seem to sit still. “He’s run by a motor,” she says, “he’s always been this way, full of life! But he’s really struggling at school.”

Attention-Deficit/Hyperactivity Disorder is a real disorder, that in broad strokes, can present in two different ways. There is the hyperactive sub-type, which is probably what most of you picture when you think of ADHD. Less recognized is the inattentive subtype of the illness, previously known as ADD. These are people and kids who can zone-out and have trouble maintaining attention, but are not running around the classroom (as a clinical pearl, women tend to present with the inattentive sub-type, and males with the hyperactive).

So what is ADHD, other than a hyper kid? To understand that, we must first understand what are psychiatric diagnoses. You can read more about that here. The punchline is that a feature of personality, behaviour, or mood, only becomes an illness when it begins to interfere with functioning. If you’re an anxious person, that can be a source of strength. It makes us on time for work, helps us meet deadlines, and not forget our wedding anniversary. If your anxiety gets to the degree it begins to cause avoidance and problems functioning (for example, anxiety causing you to miss work), then you would meet criteria for an anxiety disorder.

There is a similar phenomenon with ADHD (which *disclaimer* remains poorly understood!)

pdfnormal

Our attention span lives in our frontal lobe, the front part of the brain. If we took one hundred people and tested their attention span, it’s likely we would find a range of different attention spans among the population sample. If we plotted this on a graph, it would likely look something like the picture to the left. Attention span would be on the x-axis (bottom), and the number of people with that attention span on the y-axis (side). Note that the numbers contained on the graph in this post are meaningless and are just for understanding!

A quick interpretation of the graph allows us to arrive at some conclusions. Most people have an average attention span, represented by the peak in the graph. Some people have a superior attention span, the plateau on the right side of the graph. The plateau on the left would be those with poor attention spans. So in summary, there exists a spectrum of attention spans, with most people falling near the middle, with some people (outliers) on the edges.

diagram-of-frontal-lobe-of-the-brain — Credit: Medicalnewstoday

The prevalence of ADHD is between 5-10%, meaning 5-10% of the population have ADHD. These individuals would be represented on the graph by the lower attention span outliers, about from the “-2” on the x-axis above to the left limit of the graph. But does having a low attention span mean you have ADHD?

No!

Remember, context is always important in psychiatry! If something does not interfere with your functioning, it’s not a disease, it’s just who you are. Our society has, over time, placed increasing emphasis on an education model focused primarily on sitting in a seat. A math test is in many ways as much a test of your ability to sit still for an hour straight as it is about your skills in math. The modern day office is in many ways a person with ADHD’s nightmare. If you take the same child and place them in a playground, a gym, or a more active form of education, you may find they excel. Many of the people diagnosed with ADHD today may find they did not qualify for the diagnosis one hundred years ago, when time spent at a desk was minimal. All of that to say, ADHD exists, and is a result of the direct interaction between our individual attention spans and societal expectations!

So do we medicate these kids, if a change in environment can sometimes optimize functioning? That’s a complicated question. The answer is (usually) yes. The impairments in functioning caused by ADHD can be life changing. Academic and vocational success may depend on it. Happiness in relationships, impulsive anger, and substance use, are all impacted by treated/untreated ADHD. The reality is our ability to change the environment in our regulated world is extraordinarily limited. The fact is we are all expected to graduate high school, and that’s that. While some parents find success for their children in alternative school systems with different education models, in my experience this has a limited benefit.

It’s not all doom and gloom. Treatment for ADHD is 85% effective, among the highest response rates for any medication for any illness. Ever.

I recently met a middle aged man presenting with problems losing things. He was worried he had dementia. This man worked as a camera man for an international news agency, and his work brought him all over the globe. He has worked in countless battlegrounds, war torn countries, and environments on earth that I cannot begin to imagine. And he excelled at his job. On further history, outside of occasionally losing his keys, the remote, or his cell phone, he wasn’t really having any issues. He had many of the features of ADHD and may very well have met criteria for the illness, particularly when he was school-aged, based on his old report cards which he brought in at my request. This man, however, had found a partner and an occupation which were not only tolerant of this mans attention span and resultant behaviours, but embraced it.

“So doc, do you think I have ADHD?”

“Nope!”

Editor’s note: Often times I meet people who later in life, after high school and college, find a niche job that works for them and they can reduce or even eliminate the need for medications. If your child is struggling in school due to ADHD, I highly recommend treatment, because it can have life changing consequences!

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

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.

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…”

action automotive car employee — Photo by Pixabay on Pexels.com

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.

man pouring water from dipper on blue and grey house — Photo by hitesh choudhary on Pexels.com

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.