The Psychiatric Interview and the Biology of Mental Illness

By David Laing Dawson MD

I am tired of the mind/body argument, the dichotomy. I am tired of hearing about “new” models, theories, and psychotherapy processes, new gimmicks. I am as tired of the overreaching DSM IV and V as I am of  mental illness denial.

Here is what a psychiatrist actually does, or at least what I do:

I read whatever information is given to me about the patient I am about to see. From this I am already formulating some lines of inquiry, some hypotheses to be considered. The one certainty at this moment is that I am seeing these people because they have a problem and they want help.

As my patient or family enters I am watching them, how they interact, how they sit, walk, speak, what their eyes are telling me. I say or do something to break the ice, from the weather to the news to the book the eleven year-old is clutching or the new Blackberry his mother is putting back in her purse, or the pink Samsung the teenager is holding as if it were a lifeline to planet Earth.

And then I ask questions and listen and watch. The questions are not random but neither are they detached from the reality in the room. Some are derived from science and experience, some from high and low culture; some are designed to ease my patient’s or family’s journey to full disclosure of the whole story. And right from the beginning and throughout this process I am asking myself if I should be thinking of this, this problem unfolding, as an illness, an illness derived from its biological origins, or as a psychological reaction to something, as a parenting or family problem, even sometimes as a broader social problem, a misfit of school and child, as a serious harbinger of a life long deficit, or merely a developmental stage, a passing thing, and even if it might really be no problem at all, just a bump in the messiness of life. And always, how much is this present realty, this “talking to a psychiatrist”, impacting the story I am hearing?

Sometimes I know the answer to these questions by the end of the appointment. Sometimes I know that I will not know the full answer for a month or a year or two. Sometimes I fear I will never know.

But, far more importantly, I am also asking myself these questions: Is someone suffering? How badly is he or she suffering? Do I (we) have the means to alleviate this suffering? And my choice of the means to alleviate this suffering will depend on the patient and her family’s feelings, thoughts, convictions as much as my own interpretations and conclusions. And of course, that prime directive, “Do no harm.”

But, if you have sat on a mattress beside a young man in a full-blown schizophrenic psychosis, or paced the corridors with a manic librarian, or sat for any length of time with a woman in a state of agitated depression, or debilitating obsessions, you will know that a.) There is a lot of suffering here, and b.) These are brain things, biological illnesses.

It is not an uncomplicated matter. The  modern concept of disease has only been with us a hundred and fifty years or so. And this very concept, this idea of disease, could well be the reason you are alive reading this now, and did not die from diphtheria, pertussis, polio, perhaps cancer – or be more crippled than you are with arthritis. It is also the concept that has allowed us to successfully treat severe depression, mania, psychosis.

I am sure some of my colleagues over-use the illness/disease concept when trying to understand a perplexing behaviour. And some I know under-utilize it.  I’m sure I get it wrong sometimes. And many non-physician mental health workers simply apply the feel-good concept of the month, or bypass any attempt to understand the problem, it’s roots and pathways, and focus instead on strengths and goals and those things that we all know contribute to a healthier life.

Fair enough. But instead of arguing about concepts of illness/disease/mind/brain/body, we should focus on relief of suffering, and helping someone return to a level of functioning he or she desires, and we should use all the tools in our tool box to accomplish this, providing we have evidence they actually work.

 

 

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13 thoughts on “The Psychiatric Interview and the Biology of Mental Illness

    1. Dr. Dawson’s post is clear, honest and shows what any good psychiatrist is faced with when trying to help treat and cope with overwhelming circumstances . I hope that some younger psychiatrists would read this articles and take lessons from it. .

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  1. The DSM has been the equivalent of a psychiatric Farmer’s Almanac, used only to ensure that almost every pet theory was listed on it..

    Because that list determined which mental illnesses would be recognized by health insurance, Thank heavens scientific brain research brought some reality to the subject.

    Still, it is dog`s breakfast of unscientific presumptions. It needs to be sent off to the graveyard of misperceptions about chromic brain diseases. .

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  2. Wish you would give your views on the concept of “Recovery”.

    Here is a quote from a popular blog by Liza Long: “When local and national mental health policy is shaped by high-functioning consumers who have been able to manage their illnesses rather than by the sickest patients and their families, it’s the equivalent of only allowing stage 1 cancer survivors to drive the narrative and take most of the funds”.

    This concept is pushed by those high paid zealots who do not have a clue about the experience of families who see their sick relative day in and day out.

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  3. Dr. Dawson, I was passionately with you all the way to the end where you spoiled it for me when you wrote, “providing we have evidence [the tools] actually work.” Within your own model of treatment there exists enough evidence that it does not work. What does work is everything you described you do, as all mental health practitioners should be doing; observing, thinking and alleviating suffering. Yes, in my 30 years of working in mental health, I have sat on a mattress beside a young man in a full-blown schizophrenic psychosis and paced the corridors with a manic librarian and sat for any length of time with a woman in a state of agitated depression and debilitating obsessions, and more, and I know that a.) There is a lot of suffering here, and b.) There is more than just the brain things, biological illnesses that is going on. And because of this knowledge, the reality of the complexity of mental illness, I fill my tool box with the diversity needed to connect the individual with the right tool or set of tools. The evidence is in the results, not the theoretical framework.

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    1. Sara, I don’t disagree. I did not mean to imply that the “evidence it works” had to come from a scientific study of a large grouping of individual people, each of whom might find comfort, help, and solace from different things and activities. If it helps without harming, that is sufficient evidence.

      David

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      1. I think that the tool box must be tried to relieve anguish of serious debilitating symptoms . And something in the tool box often works or at least improves matters however slowly.

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  4. Amazing summary again, my thoughts exactly….our brain, mind and it’s intricate function throughout our lives is nothing short of complicated, truly. I do believe science and education are the links to alleviate at least some of the suffering of so many people with mental health problems..especially severe mental illness …better medication is my hope.

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  5. I am not being crass when I say I long for Dawsonism to enter our language and be taught in medical and nursing schools!

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