Psychiatry – Page 4 – A millennial's musings

Exercise and thinking

I recently chanced upon a study showing that aerobic exercise can be beneficial in mild cognitive impairment. It literally increases the size of the brain. The fact that we can now image brains in a way that detects this is exciting. Nobody is really quite sure what it means, but the fact that it is so tangible and obvious is really gratifying – and hard to argue with. Interestingly, mindfulness also changes brain structure on imaging.

There have been plenty of studies of this sort – including on healthy people. They show that exercise benefits one’s mood and working memory, enhanced cognitive strategies, hippocampal neuroplasticity – in short, exercise helps your brain do its thing. I wish this message was easier to spread. Exercise for a functional brain.

In my own subjective n=1 experience, exercise makes a huge difference to how I feel emotionally. It’s like a shield that keeps irrelevant noise out – and it was quite hard to believe how well it works until I tried it. At this point, I’ve been non-stop at it for over 3 years. My main motivator to stay going with exercise is how it makes me feel. Not immediately, not right after a gym session, but on average. Having said that, isn’t our motivation nearly always how it makes us feel? How I got into it was the classic monkey-see-monkey-do dynamic. Some like to call it having a role model. During my masters, I was surrounded by a bunch of health-freaks: they were all from continental Europe, wore fancy running shoes, drank a lot of coffee and read the Economist. The enthusiasm with which they discussed running routes for their new city, whether or not a Fitbit is worth the investment – and so on, rubbed off on me. I had to try this, ze fitness. I never stopped.

I’ve experimented with running, spinning, HIIT, swimming, weights – pretty much anything that is solitary and non-competitive is good. During a particularly busy stint at the hospital, I injured a joint – meaning I couldn’t properly weight bear. I could barely get around the seemingly endless corridors of a large Dublin hospital with nobody to cover for me on call. Exercise was not on the menu. About a week into this state of affairs, I noticed that I was starting to get sad for no reason at all. It took some introspection to figure out that it was likely down to the fact that I wasn’t exercising. The biochemistry shifted, the chemicals released during exercise wore off – and now I was feeling down. I took corrective action: so I cannot weight bear. Time for abs of steel! As if. In any case, the change in my mood from a week of significantly diminished physical activity was stark.

This experience is echoed in the story of a patient I once saw in a psychiatric hospital. He was a young guy who exercised a lot: 20 miles on a bike every day, marathons, the works. For about a year and a half he attended a cardiologist about a chest pain. He had virtually every conceivable test done – none of these tests detected any abnormalities. By the time he saw me, he had had a few attacks of this chest pain in the space of a few days – and a very low mood. The week before two things happened: he twisted his ankle and his girlfriend had just broken up with him. Long story short, the man’s chest pain was psychosomatic. He had a perfectly healthy heart. The stress of his girlfriend breaking up with him, superimposed on not being able to exercise due to a twisted ankle, led to the mood collapse as well as the chest pains.

Clearly, exercise is addictive. This is part of the reason why people keep exercising despite pain. Before I discovered the absolute must that is a foam-roller, I caused a repetitive strain injury in my calf from running too much. I couldn’t really stop: I was so into it, I just gobbled down two Nurofen and off I went. If, six months previously, someone told me that I would be like this, I would never have believed them. My buzz was all about cuddling up with a book and drinking hot chocolate – not hopping around with a painful calf in the permeating Dublin rain.

Once a psychiatry professor came to talk to us during lunch. His opening question was: “What is the single most effective intervention for both physical and mental health?” Some annoying know-it-all raised their hand and said: “Exercise.” (Okay, okay, it was me). I would still say it though.

I think it is the perfect example of the 80/20 rule, or even a 99/1 version of it. Exercise takes up very little time – if you’re clever about it – and delivers unbelievable results. In short, exercise is definitely on the to-do list of anyone who is interested in having a clear head. It’s surprisingly easy to get carried away into fitness-junkie territory, however, it is definitely worth the risk. In any confusing situation, it’s mindfulness and exercise.

To help, or not to help

Milton Erickson was an American psychiatrist who is highly regarded in certain circles. I didn’t know what to make of him – he is best known for his work in hypnosis – and so I wanted to have a look at his work for myself. Luckily, there are a few videos of him. While I don’t necessarily subscribe to his theories and explanations, he does seem to have a lot of insight into human behaviour. He recounts a story of a colleague, a psychiatrist who demonstrated avoidant behaviour in his personal and professional life. Erickson had numerous opportunities to intervene, but in the video he declares that he didn’t have the right. Among doctors, there is a doctrine that unless you are asked, you generally don’t intervene. Obviously, we don’t wait for a patient to point out gaping wounds and pools of blood – we intervene. As a spotty teenager coming in for bronchitis, I’ve left the GPs office many times with advice to drink plenty of fluids and sleep – but no word about the spots, though she hardly missed them. You get the gist.

I always wondered about the concept of having a right to help someone. Not just in a medical context. If you are in the supermarket and you see a woman who’s skirt is tucked into her tights, do you tell her? Or is it not your place? If your friend is stuck in a toxic relationship or getting too accustomed to alcohol – do you interfere or is in the their family’s job?

Inevitably, it is difficult to be the one to call the bad news out. The person whom you are trying to help will resent having their issues pointed out – even if you are as supportive as can be. Some people may even see this as a form of confrontation. I think culture play a role. The level of insecurity of the person in question is also important. However, it seems to me that if you want to be helpful, certainly if you call someone your friend, it is an ethical obligation to help.

This doesn’t mean they have to change, or even accept your point of view. Maybe, Erickson’s friend wouldn’t have wanted to hear about it and, filled with resentment, would never have spoken to Erickson again. Maybe, teenage me would have felt that the GP was being horrible criticising how I look. However, I feel there’s something genuine about being more open. I think in truth the main motivation to not volunteer to help is fear of resentment – not respect for autonomy. People opt for superficial relationships rather than a gamble between a deeper relationship or drifting apart.

I feel that it takes tremendous courage for someone to ask for help. This is another reason why I err on the side of reaching out first. I am sure many teenagers wish that somebody would just tell them that their acne needs to be treated. I am sure many people who are abusing alcohol, self-harming or losing too much weight will never ask for help – but are silently screaming for it. I am still in touch with a beloved former teacher of mine. She will never go to the doctor – she subtly explained that her blood pressure is all over the place. Is that enough to have the right to help? I jumped at it.

It’s a risky strategy, and you will surely lose some friends over it. At least, you will always know that you were a friend.

The importance of self-awareness

I often think of The Great Gatsby. While everything in it has been said before, it seems like a particularly easy-to-understand piece on human nature – not least because it seems to be reflective of what our society looks like almost 100 years on. Gatsby was great because he was motivated by love and incredibly focused and resourceful in his quest. There were also many reasons why he wasn’t great: he lied about his origin, he lied about his name, he was a criminal, he had no problem seducing a married woman with a child… Most of all he got carried away from reality. He didn’t see Daisy for who she really was even though it should have been obvious. He suffered from infatuation, limerence and obsession.

There’s an interesting dichotomy that arises from obsession. On the one hand, it is a way to get motivated like nothing else. I was recently listening to an interview with Travis Kalanick, the CEO and co-founder of Uber, who talked about how he chose his idea. He said he was in love with the idea of Uber. He also said that after you fall in love with your idea the hard part is to adjust it to the world so that it is exactly the best it can be. It seemed that all great entrepreneurs develop their businesses for some kind of personal reason. Mark Zuckerberg said that Facebook was something he would have wanted to use for himself. He seems fascinated with how people have huge areas of the cortex dedicated to deciphering the meaning of facial expressions, seemingly minor detail. The kind of motivation that’s required to spend every waking hour you’re not doing coursework in one of the top universities working on social websites means intense interest. Whether it is obsession or not, it’s close to it. Our culture seems to value obsession. In fact, the word has connotations of real dedication and martyrdom. There are gyms called Crossfit Obsession. A “normal” person couldn’t have the level of dedication that these entrepreneurs have, or a particular variety within the men and women of Crossfit – we’ve all met them. A healthcare professional would surely class them as having traits of OCPD, or find a way in which their activity is a form of escapism.

However, all great entrepreneurs are sufficiently in touch with reality so as to know how to adapt. This brings me to the second part – obsession needs to be balanced with reality. For anyone who knows the feeling, they know that this is much easier said than done. When one tries to reflect on reality, it is easy to slip into denial. Alternatively, it can be easy to see the flaws, decide that you obsession is silly and give up on it. It is much harder to see the flaws and incorporate this information meaningfully into your quest.

This idea of either idealising or damning your quest first came to me when I was dealing with patients who had emotionally unstable personality disorder as a doctor. People with EUPD tend to undergo something called splitting: something/someone is either perfect, or they aren’t worth thinking about at all. In fact, this is characteristic of many personality disorders. For example, people with narcissistic traits are very quick to decide that someone’s opinion is worthless if they don’t like something about this person.

How is it that some people are able to benefit from the momentum of obsession, but not dragged down by the unhelpful ignoring or reality or give up on their idea at the first sign of imperfection?

Are these great entrepreneurs necessarily all free from toxic personality traits? Not at all. It must be possible, however, to be sufficiently self-aware so as to let those parts of your personality that you need the most at a given moment to fully express themselves. After all, all these personality traits that we regard as vulnerable – and put them down as traits of personality disorders – evolved for a reason. They made sense in a context. They are only called abnormal because they stopped being adaptive when the environment changed, but the person who developed them lacks the self-awareness required to acknowledge that they are using legacy software – never mind adjust again. So it’s not like there’s just one personality type, not one strategy that will carry you through, but like Darwin said – it is the most adaptable that makes it through. Adaptability is completely a function of self-awareness.

So, how could we hook up with some of that self-awareness? My hypothesis is, as always, by paying attention to it. It is surprising how commonly people are unable to describe how they feel. How do you feel right now? Is it easy for you to answer? In normal life – and in psychiatry – I’ve met pretty high functioning people who are unable to answer that question. Really and truly, they look at you like you are an alien, look away and after about 10 seconds they say, I don’t really know. It’s obviously a spectrum and it’s not uncommon. Some of these people will try and assess how they should feel, making cognitive judgements about their circumstances. It’s called alexithymia. I think this is the first step. Ask the question – how does it feel? Putting words on it is a good place to start. Tackling physical sensations first could be an even better idea. When you notice that you are hungry – how does it feel? Is there a pain in your abdomen? Where? What kind of pain? Is it a cramp or a dull ache? Is there some nausea that comes with it? Does your abdomen feel warm or cold? Essentially, it is a form of mindfulness. With some practice it will be easier to put words on your feelings, or your inner state. It’s not a case of needing to soul-search. It’s not cognitive, it’s all about feelings. Whether we like it or not, emotions play a decisive role in our behaviour – they give rise to our behaviour, that’s what the word means. I think that mindfulness has the potential to increase self-awareness like no other instrument at our disposal. Mindfulness is known to increase empathy. Self-awareness is no less important. People who lack empathy are probably lacking insight into their own feelings to begin with. It may even make sense to think of self-awareness as a form of inner empathy.

If there was one thing that I think would advance someone’s personal development by leaps and bounds – it would be self-awareness. It doesn’t matter that you aren’t the strongest, the tallest, the smartest – or whatever, but if you able to be sufficiently self-aware so as to surround yourself with the right people – you can compensate for those weaknesses – and focus on your strengths.

When the going gets tough

A few days ago, for the first time in years, I found myself in a horrible mood – completely out of the blue. On reflection, I got into it through comparing myself to someone else, being inflexible and impatient under the pressure of my own big dreams. Had I not known better, I would have thought I was suicidal. I was thinking of how I owe it to the people who love me to keep going. I knew that I felt like this before. Because of that, cognitively, I knew it would pass. Cognitively, I knew that the kind of words that were floating around in my head were only words that clumsily tried to explain how much pain I was in. All the same, it was a really dark three or four hours of self-hatred and hopelessness. It was made worse by the vicious cycle of feeling guilty and weak for feeling bad.

Cognitively, I knew that the faster I interrupt this horrible mood, the better. Bad moods beget more bad moods. At this point, I stopped judging myself for feeling bad, acknowledged that this is simply the way it is – good or bad – and it’s time to get myself out of this horrible state. But how? How do you get yourself out of this mood swamp? Common wisdom would say: look for support. I couldn’t fathom talking to anyone. I know now that it’s silly, but there was no arguing with the upset-me. Common wisdom would say: try and feel grateful for what you have rather than feel bad about what’s missing. That just seemed like some kind of evil joke.

The answer, as always, came from asking the right question. The question I asked was: What’s useful about this? I knew this lesson from before. I’ve even written about it here. It just goes to show that these lessons aren’t only cognitive. It takes time and iterations to learn them. Even with all my knowledge, it took me a bit of digging around to find where the right button was.

What was useful about it? I knew that I need time to look after myself. In and of itself, that was useful information. I looked back and wondered what upset me – I learn from that too. It wasn’t the first time that being super focused and not flexible enough got me into trouble like this. However, rather than judging, I will just take this is another data point and another note to self: be more flexible. This is high level theory, but I’ve already implemented measures that would make it easier for me to be more flexible. I also realised that today wasn’t a good day to do any work. My alarm bells went off – I am glad that I don’t have to work?! Rather than accusing myself of laziness, I dug deeper. I was doing something important, repetitive – and boring. It was super easy. I am sure many people don’t mind those kind of tasks, but I can’t handle them at all. My relentless focus on doing what needs to be done got me into a situation where I couldn’t play to my strengths. So here’s another lesson: doing things that don’t come naturally for too long isn’t sustainable. I think that’s valuable as next time I will be able to assign who does what and when better.

As I am writing this, I am able to not just hope that that horrible feeling never happened – I feel grateful that I learnt from it. I really mean it. It’s all about learning, progress, small wins and getting closer to the person you want to become. And not judging.

The truth is, it’s highly unusual for me to get upset. I wasn’t just born this way though. There was one thing that made me go from super sensitive to where I am now. When I say super sensitive, I mean if the person who poured my coffee in the morning looked at me wrong – I would feel uneasy for hours. What made the difference for me wasn’t some sort of soul searching or even mindfulness – it was straight up physical exercise. I don’t know whether it is just the flood of endorphins, but it really helps with the art of just not giving af when appropriate. Exercise is the one thing that makes the biggest difference to both mental and physical health for a healthy person.

There was some cognitive work too, but it would never have happened without the initial boost through exercise. The cognitive work was something like this: the barista doesn’t care about you, you are just a person with an order and a wallet. They are in their own world. It’s not personal. They are just trying to get through the day the best they can. I think there’s a word for that – it’s called empathy. Exercise isn’t known to cause empathy, what’s going on here? Exercise requires focus, so in a sense, it requires mindfulness. Maybe that’s part of it. In any case – in my unblinded non-randomised non-controlled trial of n=1, it works.

How to stop worrying about things that may never happen?

After blogging for less than a week, I am getting contacted by the audience – this makes me so happy! J. wrote:

I’ve recently started meditating and practicing mindfulness. I downloaded a couple of apps to help make it apart of my daily routine, but still have fears if I’m “doing it properly.” I guess this is a normal fear for most people starting out but I tend to overthink things that are seemingly out of my control. I’ve had this problem for as long as I can remember, dating back to my adolescence. I suppose my question to you is, how do we stop worrying about things and situations that are probably never going to happen?

The first thing that comes to mind is one of my favourite quotations from Mark Twain: “I am an old man and have known a great many troubles, but most of them never happened.”

Even the way J. phrased the question is so interesting: how do we stop worrying about things and situations that are probably never going to happen? Clearly J. cognitively understands that his fears are unfounded: the things he fears are probably never going to happen. However, intellectually understanding something doesn’t always help us feel it. Depending on your personality, it may of may not be possible to outthink a feeling. As an ENTP, I only require a conscious realisation to change the way I feel. The answer is always within us.

What does worrying do for us? Why are we so addicted to it? How do we manage to continue to worry even though it hurts so much? The answer is that on some level we believe that worrying is better than not worrying. How can worrying be better? It is better because it keeps us safe. In a sense, it makes us feel like we are in control. If we are always looking out for what can go wrong – bad things are less likely to happen. This is a likely core belief for someone who worries a lot. Our brains are evolved for fear: fear is the software that keeps us safe. As a species who is only 200,000 years old and whose conditions have changed so starkly in the last few hundred years (food is more available and sabre-toothed tigers aren’t that common), we haven’t managed to change this core software of fear. Fear is our friend. It has kept us alive as a species. There comes a point where it just isn’t feasible to keep budgeting for the downside. Once you are prepared, once you have addressed everything that is in your control, that’s it. Fear is no longer useful (we’re not taking about survival situations).

Seneca’s letters are incredibly helpful when it comes to dealing with anxiety in my experience. The thought of reading or listening to an Ancient Roman philosopher is daunting, but it is surprisingly approachable. Seneca wrote a bunch of letters to Lucilius – and these letters are often regarded as a key text in stoic philosophy. They read like a reddit post though! Letter XVIII. On Festivals and Fasting talks about putting yourself in controlled situations that you fear. It’s not about leaving your comfort zone or skydiving if you are afraid of heights. It is considering: what is the worst case scenario. The outcome is that you become less afraid.

It is easier to believe something when you see it. Everyone has friends who are chill no matter what happens – they are the people you want to spend more time with. Maybe that’s not possible, but you have the internet – lot of bloggers, youtubers etc, who laugh in the face of fear – people who do extreme sports, etc. Seeing that another point of view exists is always helpful in getting out of a rut.

You can also play word associations with yourself. No thinking allowed. Just blurt out the very first thing that comes to mind. Say fear – what would you say next? I was very surprised when I did this exercise. The first thing that came to me was abandonment. Fear of abandonment is a very real thing. Cognitively, I thought that I would be afraid of not achieving certain goals. What bubbled up in this interesting exercise was that I was afraid for my relationships. It didn’t make cognitive sense before it happened, but when it did – it gave me a huge insight into a whole part of my life I was hiding from.

How does mindfulness make this better? It allows these fears to crystallise – when fears are less vague, they are easier to handle. It allows things that we are hiding from to bubble up and be dealt with. And of course worrying is a habit. It requires certain pathways to strengthen. By directing what your mind is doing, it is easier to replace the worrying habit with something much more productive. Scientific evidence that I will go through another time supports the idea that mindfulness helps with anxiety.

Some philosophers and psychiatrists believe that we only have two fundamental emotions: fear and love. It doesn’t make much sense at the start, but on reflection: what is anger? It is fear that someone is crossing your boundaries. What is regret? It is fear that you missed out. What is sadness? It is fear that life will never be this good again. The ultimate fear is that we aren’t deserving of other people’s love, that we’re not good enough.

In that vein, the only way to deal with fear is to focus away from it – onto something else. Instead of asking what can go wrong, ask how can I make it better? Instead of asking how do I avoid peril, ask how can I get what I really want? Instead of asking how do I stop worrying, ask how do I help my friend stop worrying? Our brains will probably default to looking for sabre toothed-tigers, unless we ask the right questions.

What having no idea about psychiatry is like

In all my time in medicine, psychiatry was certainly the steepest and most unexpected learning curve.

The truth is that I started off as a pro nerd who wanted to be a surgeon. When they said medicine is an art and a science, I was just waiting for them to stop. In medical practice, choosing an antihypertensive drug is not an art. Perhaps, looking for new mechanisms of action is more creative, but not the practice of prescribing. There are scientifically rigid algorithms on how it should be done as of today, and the rest is harmful heresy – not art.

When I was in first, second and third year of medicine, I was convinced I wanted to do general surgery. Possibly paediatric. I took serious steps to that effect. I found a family friend who was a surgeon, and aged 19, I was spending my summers doing 36 hour shifts of shadowing surgeons. Scrubbing in on critical abdominal aortic aneurism ruptures, appendectomies, cholecystectomies, you name it. I learnt much faster in those 3 months of summer than surgical trainees in their cursus honorum residency.

At that time, I was shaping up to become a pragmatic and practical surgeon. We all know the kind of culture that is prevalent among surgeons – especially 10 years ago. Needless to say, it rubbed off on me too and I was expecting psychiatry to be a wishy washy waste of time. There was no stigma, no prejudice, no resistance – just an expectation of something I will have no interest in.

Then my college experience of psych began. I recall being late to the first lecture and sitting down at the back with one purpose only: make sure I am signed it. I wasn’t expecting to learn anything other than a bunch of genetics concerning schizophrenia and Alzheimers and be lectured on good communication skills.

I was so wrong.

My attention was instantly captivated by the lecture. It had nothing to do with the lecturer: he was ok, but it’s not like he was ultra captivating, charismatic or whatever. It was the substance of what he was saying. The lecture was on something called phenomenology (the study of subjective experiences). So for example, I learnt what the difference is between an illusion and a hallucination. What knight’s move is. Perseveration. Running commentary.

It was fascinating. It was like a parallel universe just opened up to me. I was entirely unfamiliar with all of these things. No portrayal of these phenomena in films comes close to actually considering what it is like, never mind meeting a person who suffers from such a thing. Maybe A Beautiful Mind is a place to start. But still, it barely, I mean barely, scratches the surface. I was in the industry, I was top of my class and yet until I went and properly exposed myself to it – I was so so ignorant. It is important to realise that the general population, no matter how educated, has absolutely no idea what a person with a severe and enduring mental health problem goes through. Zero.

As a fervent advocate of the scientific method, I would like to point out the role of art in this. It’s not art in some kind of mystical, deeper meaning sense. It is art in the sense that it is creative. Surgery is creative – but in a practical sense. It’s just a more conservative field.

Psychiatry is cognitively creative. It’s not algorithmic like most of medicine. Much of it has never been done before. The DSM differs so much edition on edition, that it is clear that we haven’t even come close to understanding what’s really going on. Paradoxically, the actual practice of psychiatry is quite intuitive 90% of the time.

Ten percent of the time, though, psychiatry requires a doctor to think outside the box in another dimension. Because you cannot MRI someone’s brain and say – this is mercury poisoning, not dementia. This isn’t depression, this is catatonic schizophrenia. You really need to not just think, but rely on something less tangible – does it feel like this person is depressed or does it feel like it’s EUPD? Freud tried putting all kind of names on these intangible feelings. It’s just a first attempt. Is it possible that both of these diagnoses are missing the point of what’s really going on beneath the surface and in another 20 years the DSM will have neither of those in it? If House solves puzzles, this is solving puzzles when you have no idea what the resulting picture is going to be.

Psychopathy vs control of emotion

I recently learnt that I have the val-val variety of the COMT gene. This piece of information means I respond to stress pretty well – the weight I attribute to it is tiny, but it is also characteristic of the ENTP personality type, so I will roll with it.

Looking at other women freaks me out sometimes – they are so emotional. Everything seems to matter. I feel like I have the full range of emotion, but being around these super intense women sometimes makes me feel like either a man – or a psychopath. I just can’t relate – and it makes me feel isolated. Furthermore, I never thought of myself as being super-empathetic (though I still cannot watch A Christmas Carol even without crying.) So I don’t know what to make of it and am starting to wonder if I am a tad psychopathic.

Controlling emotion, being aware of emotion and using it rather than allowing it to use you is fundamental to getting anything done. I struggle sometimes to understand the difference between controlling emotion, suppressing emotion and being a psychopath. In the words of Robert Frost, the only way out is always through, but sometimes it seems that the drama just passes me by.

So let’s say someone hurls an insult your way.

A number of things can happen:

A. You feel that the only thing you can do is react. [Stupidly reactive]

B. You are in tune with your emotions, you will feel the anger as a response within you. Having this awareness will allow you to then decide: ok, there has been an insult, now I feel angry, but what am I actually going to do? [Zen master]

C. You know that this person’s opinion isn’t everything, so you don’t care, so you don’t get angry. You respond is an entirely calculated way. [? Psychopath]

D. You feel the anger, feel offended, but you are the bigger person, so you delay the response – and think of a way to respond while feeling vulnerable and under attack. [Suppressing emotions]

B and C seem like good options. The problem with C is that most people would regard it as psychopathy. But what if you control your emotions from a cognitive perspective? If you develop a belief that a person’s opinion isn’t important – that’s not psychopathic. And the fact that it diminishes your emotional response to the point of not existing – is also understandable. As a baby you could be afraid of the loud noise that the hoover makes, but when you get a little older – you understand that there’s nothing to be afraid of, and so the fear that had previously made you cry – goes away. Similarly, not every person is entitled to an opinion on every subject. **A conscious decision to not care with good reason is different to being someone who is unable to care, i.e. a psychopath.**