Thursday, February 19, 2015

Psychiatry induced psychic musings -- but not the schizotypal type; no tea leaves other than my Earl Grey considered

The Power of Analogy

When I was a younger some of the best times with friends involved philosophical meanderings that only a teenager could sincerely believe were original revelations. An idea that I "happened upon" was based on the premise that all of the physical tools we used in the world (hammers, pulleys, fasteners, wheels, and even motors share mechanical principles with the highly conserved "9+2" arrangement of the flagella) could be traced back either in direct or indirect etiology to an anatomical structure or functional component. At the time I was not filled with a burning desire to be a physician and my knowledge of the history of anatomical studies -- one of the ancient scientific disciplines was all but unknown to me. But, even at that supremely awkward season that is post-pubescence, I was in love with the idea of knowing and interpreting the world through analogies and metaphors. If I had only read something like this fascinating article by Robert B Trelease, Ph.D, that discusses how to bring the storied history of thousands of years of anatomical study into the informatics age. I did not know it at the time, but the driving force that pushed me into medicine was germinating even back then. As I’ve gone through years of intensive training one tool that has proven to be invaluable is tying abstract ideas to familiar ones – better comprehension through analogy. 

Analogies can serve more than one function – this excerpt from this collection of articles detailing medical analogies and their various functions details how the man who first came up with the stethoscope did just that:

In 1816, I was consulted by a young woman labouring under general symptoms of diseased heart, and in whose case percussion and the application of the hand were of little avail on account of the great degree of fatness. The other method just mentioned [application of the ear to the chest] being rendered inadmissible by the age and sex of the patient, I happened to recollect a simple and well-known fact in acoustics, and fancied, at the same time, that it might be turned to some use on the present occasion. The fact I allude to is the augmented impression of sound when conveyed through certain solid bodies, - as when we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other. Immediately, on this suggestion, I rolled a quire of paper into a sort of cylinder and applied it to one end of the region of the heart and the other to my ear, and was not a little surprised and pleased, to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear.


Not too dissimilar to the penchant the general public has for consumption of “top 10” or “top whatever” lists is our ability and sometimes, compulsive need to quantify all aspects of life. Analogies are just this same pattern of comparison but instead use the ability for comprehending a novel process by associating it with a known process. 

Just as the movement of the thorax and the hundreds of individual components all moving in concert to allow us to breath is fascinating on a level that elicits contemplation concerning the origins of us as individuals and species; so much more is the wonder of the human mind. A mind that has, in billions of individual brains throughout history, proven to have a pattern of using analogies to understand new or perhaps, more abstract concepts. Elegant analogy employment sees two normally disparate things provides a relationship all in the aim to provide understanding about one of the processes not in merely an additive way, but in a synergistic manner.  

Now I am a medical student, a little over a year away from actually being a doctor. I have spent countless hours studying anatomy and the relationships between structure and function. While it is notoriously difficult to learn the relationships between the startling distinct components of the central nervous system compared to, say, testing for ligament damage in a knee, recognizing both is a huge component of psychiatry -- it is the recognition of dysfunction and the discernment between acceptable parameters and pathologies. It is this ability to discern which has resonated with me more than anything in my time spent with Dr. Levin for the past month. 

I now see certain childhood behavioral issues not as a collection of neurotransmitter issues and immature prefrontal cortices (of course, knowing these things is imperative – and at certain stages, communicating with patients and patient’s families using analogies becomes valuable, once the practitioner masters a concept) but as a powerful muscle car with a ridiculously reactive accelerator, coupled with weak brakes, low-fidelity steering and of course, an inexperienced driver. While it is helpful for me, as a student, to see these things in simplified terms, I have witnessed numerous worried parents come to a better understanding of what their child is going through. They see them as a vulnerable child trying their best to operate a car that is years beyond their level of capability. Of course this doesn’t excuse bad behavior, but a working analogy can serve to guide a parent in how best to manage behavioral issues. 

While describing a blood vessels as pipes that carry water in a house miss much of the vital function that blood vessels can serve, such as constriction, dialation and even allowing cells to go right through their walls, we can all agree that the basic function is very similar to our home’s water pipes. And so I will leave you with this: an analogy is like a car; if you take it too far, it will break down. 

Learning wariness of emotions and the elegant balance between function and dysfunction

Treating children medically has a special dynamic in that while the reward for success may be sweeter, the pitfalls are just as hazardous and, in my mind, potentially terrifying. Just as a community especially mourns the death of a child in a way that reflects the loss of an unlived life, the reverse is true when “saving” a child from impending doom. 

Dr. Levin sees many children in his practice and observing his demeanor and ability to connect with an otherwise uncommunicative angst-ridden teenager is nothing short of awe inspiring. And, of course each patient is different and requires individualized contemplation concerning treatment plans and communication methods, a common thread is reminding the teenager not to trust their emotions. This is a lesson that all of us, on some level can appreciate – I know I can, and should be more mindful that emotions are reactive and not always from a good-natured wellspring. Like most adults, I survived the teenage years with minimal grace and elegance – partly to the fact that I trusted my emotions. What else are they there for if not to guide my immediate decision making process? That is a good question, although, practically it hardly matters why they are there and why they can be so unbelievably overpowering – it is what we do with them that partly determines our course in life. 

There is a term called “depersonalization” that describes a disorder characterized by persistent or recurrent feelings of detachment from one’s self or environment, where they feel separated from their own bodies and mental processes – often described as if they are watching themselves as a moviegoer would watch a film. Episodes are often accompanied by anxiety or panic, coupled with the fact that episodes also are more common during periods of stress. Diagnosis requires that episodes be persistent or recurrent, as transient systems. I bring this dynamic to light to illuminate the delicate balance between a utilization of some tools/behaviors associated with “depersonalization” and actually having functional impairment due to “depersonalization.” Obviously, to be able to understand that emotions are not to be implicitly trusted and to be able to actually be wary and thoughtful in the face of overwhelmingly powerful emotions takes executive function capacity that can be similar to what occurs during “depersonalization.” Does an ability to distance oneself psychologically from endogenous emotions lead to a “depersonalization” disorder? Inherent in this line of thinking and questioning is the crux of the art of medicine as employed in the field of psychiatry. 

Medications and when to use them and when to not use them, awareness of contraindications and all the other minutiae is hardly an art – incredibly important, yes but the difficult part is discernment. And, a big part of this discernment is parsing functional impairment from a normal variant comprising the same behaviors and thought patterns. If a child presents with wheezing and shortness of breath to your clinic, getting an oxygen saturation level quantifies the level of functional impairment, and assuming that this child didn’t just come from flat out sprinting for the last 5 minutes, discernment between physiologic and pathologic hypoxia is not a difficult decision. A patient that presents to the psychiatrist’s office with certain complaints, it is not always obvious, at first, whether the issue is physiologic (normal variant) or pathologic (functional impairment) and there is no analogous objective test like an O2 saturation test to easily and quickly make that judgment. Instead, the physician must rely on the patient’s narrative and reporting. 

This reliance on the patient for any and all feedback other than observation of in office behavior and affect is scary for me, a medical student. Much of my clinical training has taken place in facilities that almost exclusively treat the most depressed segment of the socioeconomic class of our society. Often, for these patients, life is comprised of survival tactics and crisis mitigation and energy and money that others are able to devout to their mental health is just not there. My time in Dr. Levin’s office was one of the first times where I felt like most of the patients were people I could easily and effortllessly identify with, people with whom I had much in common. On some level, it was most excellent for me to take part in less crisis management (as most of my training has centered around) and engage in subtler care of any given patient. Hearing parents describe how small dose regimens of methyl-phenidate has allowed their daughter or son to become a good student is very gratifying. To be able to work with parents who are themselves capable and highly functioning citizens is also comforting and allows for hope. If one’s worldview is constantly being shaped and molded by current experience and surrounding, mine has shifted into a much more hopeful place – which, considering I’ve spent the last month in a psychiatric office, is significant.