Chest pain is in your head

christmas home house light — Photo by Pixabay on Pexels.com

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.”

black and white blood pressure kit — Photo by Pixabay on Pexels.com

“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.

Mental illness exists for a reason (part 1)

Damn you, Mother Nature!

It’s complicated.

Deep in the Democratic Republic of the Congo, near the South Congo River, lives the rarest species of great ape in the world – Bonobo chimpanzees. Why are the great apes important? They are the animals most closely related to humans on the planet! And they’re also the next most intelligent animals on the planet. These animals exhibit complex social behaviours and relationships, and members include chimpanzees, bonobos, orangutans, and gorillas.

Apeldoorn_Apenheul_zoo_Bonobo — Bonobo – Credit: Wikipedia

Bonobos are particularly interesting because they only live in one place in all of the world – the South Congo River. This is in contrast to traditional Chimpanzees, who have ranges all across the African continent. This has resulted in Bonobos being the last discovered great ape and have therefore been the least studied! Until recently, that is.

Chimpanzees are notoriously aggressive. Jane Goodall infamously documented a brutal chimpanzee civil war when she lived among the apes in 1974-1978. Chimpanzees have a complex social structure, with rank and sexual capital determined by violence. Bonobos, on the other hand, are like your cool uncle. They do not appear to compete for rank, males are often subordinate to the females, sex is often homosexual and not for the purposes of procreation, they are considerably more sexually active than Chimpanzees, and importantly, are non-violent!

Scientists have been trying to understand the basis for the differences in behaviour for some time, in hopes that this can lead to a better understanding of the operation of the human mind. Genetic studies have begun to uncover key differences in the genomes of both apes. It turns out Bonobos are the second most related ape to us, after the chimpanzee, and Bonobos appeared to diverge genetically from Chimpanzees between 2 and 2.5 million years ago.

So what happened?

Geological studies show that 2.5 million years ago, in the Zaire river, there was a large drought, which pushed the previous chimpanzee-bonobo ancestor out of that area. The group diverged, with the river being a dividing line. Those apes that went South of the river, found food plentiful. They were able to continue the fibre, plant-based diet the apes always had eaten. These apes are what we now call Bonobos. This was not the case for the apes which moved North. These apes had to compete with African Gorillas for scarce food resources, and due to competition and food scarcity, had to shift their diet to an omnivorous one, and include meat. These apes have evolved into Chimpanzees. You can read more about that here!

So what explains the stark difference in their behaviour? If you recall, I mentioned earlier that Bonobos and Chimps are our two closest relatives; both Bonobos and Chimpanzees are more related to each other than we are related to them. That provides a pretty interesting opportunity. Because Bonobos and Chimps are so closely related, it should be relatively easy to find differences in their genome, which provides an opportunity to find the gene, if there is one, responsible for this change in behaviour.

I won’t get into the technical stuff here, but it turns out that is the case. This study identified a key mutation in a gene (vasopressin 1a receptor gene) which occurred in Chimpazees and has been associated with lower sociability and increased anxiety. It makes sense why these traits are helpful when you are forced into competition with one another, and Gorillas, and have to hunt meat. Bonobos on the other hand carry the non-deleted form of the gene, which has been associated with increased openness to each other. You can read more in the previous link (it’s technically heavy) but the researchers argue pretty convincingly that this is the genetic basis for the differences in personality!

It turns out humans, and… prarie voles? also contain the gene for vasopressin 1a receptor. In part 2, we can use our understanding of this gene in humans to extrapolate why mental illness may exist!

Editor’s note: I do not want to diminish the role of, “nurture,” in the nature vs nurture argument. By no means in personality 100% genetic (most studies show it’s around 50%)! This blog simply looks at the genetic side of things.

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of this blog post.

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.”

boy runs at the street while people looking at him — Photo by RUN 4 FFWPU on Pexels.com

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.

Goodbye Psychiatry, I’ll miss you!

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

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

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

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

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

So what gives? I just wasn’t happy.

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

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

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

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

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

Goodbye Psychiatry, I’ll miss you.

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

Were we meant to be alone?

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

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

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

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

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

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

portrait filter grandfather — Photo by Serkan Göktay on Pexels.com

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

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

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

family of four walking at the street — Photo by Emma Bauso on Pexels.com

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

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

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

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

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

Why can’t I sleep?

BKN Raptors Return 20190615 — Credit: CityNews Toronto

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

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

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

You wonder, “why can’t I sleep?”

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

nerve-cell-2213009_1920 — Credit: pixabay.com

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

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

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

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

black crt tv — Photo by Huỳnh Đạt on Pexels.com

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

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

apartment bed bedroom chair — Photo by Pixabay on Pexels.com

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

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

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

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

The first patient I cured

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

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

“You’re telling me…”

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.