Psychiatry is Never Boring

So much is always going on in psychiatry that it’s easy to follow the 11th Commandment, “Don’t Be Bored.”  We are beginning to look at psychiatric problems not just in terms of DSM 5 diagnoses, and not just in terms of brain chemistry and genetics, and not just as the interactions of genes and environments (including fetal and early childhood happenings). With the help of increased computer power and newer mathematical statistics, research is burgeoning on the brain networks in which the 80 billion neurons (and the more numerous brain cells which are not neurons) are connecting and interacting. Some of the identified networks are those of executive control (decisions and planning), salience (meaning and importance of incoming data), attention, and default mode (related to baseline inner awareness, thinking, daydreaming, sleep onset, and much more). The activation and deactivation of networks is where the action is; I expect we will be directing our therapies to these before long.  I refer to this exciting new direction in psychiatry as the Brain Connectome Project.    There will be more to come about this expanding field exploring the network of the brain.

In my practice I look forward to listening and conversing and working with people and helping them figure out what is going on. I sometimes say that I am here to help them protect their brains from risk and use their brains most effectively as they want to. For example, in addition to problems we read about in the news, there are more subtle things going on. I have found an increase in the symptoms of depersonalization and derealization, in which we may feel we are somehow the wrong person, or in the wrong body, or that life is not as meaningful or real as it seems to be for other people. Just identifying this issue may suddenly allow someone to make more sense of what they have been suffering with.

Medical practice is always interacting with public health in general. Since July 1 of this year we are required to use the Prescription Drug Monitoring Program (PMP Aware in Georgia) whenever we prescribe certain scheduled drugs, to see what other prescribers and prescriptions are out there for any particular patient. Pharmacists must enter all scheduled drug prescriptions they fill into the data base within 24 hours. This data base has provided significant information, and has helped me identify and discuss risk issues with my patients. “Scheduled” means medicines the DEA (Drug Enforcement Administration) considers can be misused or are habit forming, such as opioids, benzodiazepines, and others. The public health goal is to reduce opioid deaths and other harms.

The number of meetings, journals, updates, courses, books, and conferences require us to be selective.  Earlier this month I attended the GPPA (Georgia Psychiatric Physicians) meeting in Amelia Island with about one hundred colleagues. There were excellent presentations of new research on, of course, the management of opioid disorders (by Dr. William Jacobs, Jr.), post traumatic stress from the Grady Trauma Project (by Dr. Charles F. Gillespie) which is nationally known, and the connections among sleep disorders, depression, stress, and suicide (by Dr.W. Vaughn McCall). I was particularly interested in findings which confirm that insomnia is not just problems sleeping, but a 24 hour type of hyperarousal which interferes with decision making, causes inflexible thinking, and increases suicide risk. We lose a lot of valuable information because drug research trials almost always exclude people with known suicide risk.

I have been reading about the increase in “deaths of despair” labeled by two Princeton economists, which includes some familiar foes:

• Overdoses and poisonings with drugs, suicidal or not (usually opioids)
• Deaths from alcoholism (liver disease)
• Suicide

All of these have been significantly increasing since 1998 in a particular population group, namely middle age and older men and women who are white and have not attended college. Of course we are all vulnerable to these disorders, but this group has seen an unusual increase.

I used the term “boring” in the title of this piece. Could it be that  boredom is a protective type of emotion which signals it is time to get curious in order to survive? Think of emotions as signals which give color and motivation to thoughts and experiences, notice what is going on in your brain as if you are in an audience and your brain is onstage.