What is Psychiatry all about?
In my career as a psychiatrist i was inspired by my patients to start this website. I felt their longing to further understand what goes on with the mind and the mood that makes it difficult to blend seamlessly with many aspects of life, non the less the essence of life, that is the sensation of joy and satisfaction
It is rather confusing that we need to chemically induce happiness, trust, pleasure, interest, motivation, logical thinking…etc.
Humans across cultures are equipped with a natural ability to evaluate reality, react emotionally to events in their environment with a huge spectrum of emotions and ways of thinking. The expression of such adaptability is varied from culture to culture. When faced with unfavorable events they all share in common the ability to restore happiness after sadness, calm after frustration, peace after fear, trust after doubt, contentment after bitterness, focus after distraction and reason when presented by evidence.
Societal norms, spiritual values and practices and emotional intelligence provide a strong foundation that help us restore regulation after imbalance in a timely manner.
To some, it is not possible… despite all personal and environmental interventions.
Why?
Many attempts to understand the psychodynamic bases of emotional dysregulation took place during the last century. Psychotherapy theories and environmental modification techniques were carried out, with partial results.
That sparked the field of neuroscience, neurobiology and neuropsychiatry.
These fields go in depth into the brain, attempt to scientifically study its anatomy and function. Initially the brain surface was mapped into areas corresponding to different sensation and motor functions. Deeper brain structures were studied comparing autopsies of normal brains to those with a history of emotional or cognitive dysregulation. Microscopic and electron microscopic studies were able to identify significant changes in several psychiatric conditions compared to normal controls. Studies of the different chemicals (also called neurotransmitters) and hormones present in the blood and the cerebrospinal fluid (the fluid that circulates in the brain and the spinal space) showed further changes. More recent Positron Emission Tomography (PET), structural and functional Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) showed further significant structural and functional changes in this population.
Observations
The observations that some illicit substances or alcohol can temporarily trigger or relieve psychiatric like symptoms, for example hallucinations, paranoia, depression, irritability, violence, mania…..etc. gave more insight into the presence of certain similar naturally occurring chemicals in the brain that could be involved in the pathophysiology of psychiatric conditions.
Areas of the brain that play central roles in emotional regulation have been identified and mapped, namely the Hippocampus, Amygdala and Prefrontal cortex among others. These areas are connected to each other and to almost all other structures of the brain and directly or indirectly to the rest of the body.
Environment
Effects of the environment on inducing or improving psychiatric conditions is significant.
A biologically identical twin has only 50% chance of developing a psychiatric condition that their twin does. Similar biological predisposition can be triggered or suppressed by different environmental circumstances. Favorable environmental conditions are protective whereas stressful ones are triggering.
High fidelity research throughout the world has replicated over and over again similar biological, genetic and environmental factors contributing to psychiatric conditions across cultures and beliefs.
How much do we know?
Unfortunately we still don’t have the tools to know precisely who is going to develop what psychiatric condition at what time. we do know factors that may increase the risk of developing certain conditions. These are more predictive than causative.
The brain is a small and complex organ. It is not within our capacity to safely obtain biopsies from target structures in the brain of living affected humans to be able to directly analyze each abnormality and have direct evidence as to their relationship to the psychiatric presentation. On the other hand other organs are regenerative. Biopsies are routinely and safely obtained with no impact on the organ itself or the rest of the body. Abnormalities are studied and evidence guides treatment. In a diabetic patient for example, pinching a biopsy of the pancreas is easily obtained at bedside. The pancreatic tissue will regenerate back. Samples are easily studied. Abnormalities of the insulin producing cells are detected and used as direct evidence to guide treatment.
In psychiatric conditions, tissue samples can be obtained from affected human brain autopsies provided they consented to the studies. In psychiatric research, most of the data is obtained from living research animals brains and body fluids of living human beings. This is a major impediment in the progress of the field of psychiatry compared to other fields of medicine.
Compiling all the research data available so far has lead to a plethora of psychoactive medications that have been extremely helpful in controlling some of the symptoms of psychiatric conditions but in no way are ultimate answers or cures.
Some major chemicals (also called Neurotransmitters) are:
- Serotonin
- Norepinephrine
- Dopamine
- Endorphins
- Adrenocorticotrophic hormone (ACTH) (also called stress hormone)
- Brain Derived Neurotropic Factor (BDNF)
- Gamma Amino Butyric acid (GABA)
- Glutamate
- Acetyl Choline
What do Medications do?
Most psychiatric medications target one or multiple of these neurotransmitters in an attempt to restore balance hence improve related symptoms.
Psychiatric conditions are like medical conditions, they have signs and symptoms. For example depression is not necessarily the feeling of sadness but could also be the mere lack of sensation of pleasure or excitement. Alongside these two come significant physical and mental symptoms like change in sleep, poor concentration, low energy, body fatigue, change in appetite, negative self deprecating thoughts, lower self esteem, guilt and sometimes giving up… suicide.
Different conditions have similar symptoms so each symptom is not diagnostic of a particular condition but rather it is the constellation of certain symptomatology that point to a particular condition.
What is the best treatment?
The approach to treating psychiatric condition is multi-disciplinary. It involves environmental interventions, psychotherapy, psychopharmacology and procedures including electrical or magnetic stimulation of the brain or the vagus nerve. Psychosurgery may rarely be necessary for some conditions.
Psychotherapy and environmental interventions are vital and necessary in almost all psychiatric conditions. There are several forms and durations of therapy ranging from a few sessions all the way to life long monitoring. Different therapy strategies target different conditions.
Pharmacological interventions are commonly used. Since it is hard to predict which neurotransmitters or receptors are exactly involved in each condition we use what is called rational poly-pharmacy, meaning using a combination of medications that act differently but complement each other in a rational way. We may start off using one medication then depending on the response/tolerance we may use others that target different neurotransmitters or receptors. Switching medications or a combination of several medications may be necessary to target different symptoms of one illness. For example, we may use and anti-anxiety medication to calm nervousness, a sleep aid to restore sleep and a mood stabilizer to regulate mood symptoms. Similar medications can be used in different conditions, hence medications treat symptoms rather than syndromes.
It takes the brain 3-4 weeks to respond to psychiatric medications. patience, environmental interventions and psychotherapy can help alleviate some symptoms until the medication takes effect.
Most current psychiatric medications have a fairly benign side effect profile. Some have potentially deadly side effects. It is extremely important for us to discuss all potential side effects with your psychiatrist so you can collaborate on how to prevent them or treat them when they occur.
I hope this introduction was helpful in the general understanding of the mind and mood.
Sincerely,
Ghadeer Okayli, MD
Board Certified Psychiatrist.