By Dr Javed Latoo, Psychiatrist
Psychiatry is a branch of medicine that deals with disorders of the mind. The mind has a physical understructure called the Brain. According to the most accepted current theory of mind, Functionalism, the brain is like a hardware and mind is like a software of a computer.
The brain is the most complex organ of the body even though it weighs only three pounds on an average. Some of the hair-raising facts about brain include that on average a brain contains about 100 billion brain cells called neurons and each neuron connects with about 40,000 synapses. It is estimated that a human brain can generate around 50,000 thoughts per day. Due to such complexities, the brain is often referred as the "three-pound universe."
Even though we use the brain and the mind for every action, their complete functioning is still hidden from our plane sight, and unfortunately, our eyes cannot see beyond our noses. We still don't know a lot about the Brain. However, due to advances in brain imaging technology and neurosciences, our understanding of the functioning of the brain and its role in mental illness is improving and is going to improve vastly over the next two decades. I believe a forest of new knowledge about the brain and mind is waiting to be discovered.
However, due to the nature of the territory psychiatrists deal with, there may always be an element of uncertainty about the exact nature of things as Psychiatric disorders develop at the fence of the matter( Brain) and non-matter ( Mind).
Psychiatry is not the only branch of medicine or science that is shrouded in a degree of uncertainty. We now know even our physical world, we are so certain about, is characterised by uncertainty and unpredictability at the Quantum ( sub-atomic ) level. The Uncertainty Principle, also known as Heisenberg's uncertainty principle, in the field of Quantum Mechanics was proposed only to highlight our limitations to know things with certainty. The principle of uncertainty was considered a blow to the believers of absolute Determinism.
Even though we do not know the exact cause of chronic psychiatric illnesses like Schizophrenia or Bipolar Disorder, but we know a lot, indirectly, by the effectiveness of medication and their mechanisms of action. Various psychiatric medications including antipsychotic and mood stabilisers are very effective drugs that help many patients to live a productive life in the community.
Regarding the exactness of causality, it is important to emphasise here that psychiatric illnesses are not different from physical health conditions. There are many physical health problems ( too many to produce an exhaustive list here) where we do not fully understand the cause of the condition. In many physical health conditions also, ( e.g. Hypertension, Cardiomyopathy, Parkinsons Disease, Multiple Sclerosis, Sarcoidosis, Pulmonary Fibrosis, Bronchiectasis, Ankylosing Spondylitis, Chronic Fatigue Syndrome, Autoimmune Hepatitis, Ulcerative Colitis, Crohns Disease, Fibromyalgia, types of Glomerulosclerosis and Arthritis), we do not know the cause of the condition.
In the medical field, we often use a word idiopathic when we do not know the exact cause of the problem. For example, In 95% of essential hypertension cases, the cause of the hypertension is not known. However, we still treat them with medications including anti-hypertensive to stabilise blood pressure and reduce risks associated with high blood pressure.
Curability and chronicity
There is another misconception among doctors as well as the public that most physical health conditions are curable as compared to psychiatric disorders. I probably would run out of space to mention all medical conditions by name that cannot be cured like some mental illnesses. My colleagues in Primary care, Internal Medicine, Cardiology, Respiratory Medicine, Neurology, Geriatrics, Rheumatology, Dermatology, Oncology and many other medical specialities spend most of their time in the management of chronic physical conditions that can only be treated but not cured.
Hypertension, Ischemic Heart Disease, COPD, Bronchiectasis, Rheumatoid Arthritis, Diabetes Mellitus (DM), Osteoporosis, Parkinson's disease, Multiple Sclerosis, AIDS, Chronic Liver Disease, Chronic Kidney Disease, Hepatitis B, Hepatitis C and SLE are just some of the chronic physical conditions that immediately come to my mind. Just like some psychiatric conditions, these physical conditions are treated to improve symptoms, improve the quality of life and reduce risks without any permanent cure.
On the contrary, many patients who develop a depressive episode might not have another episode and thus is potentially a curable disease. One fourth of Schizophrenia patients have only one episode and can achieve complete recovery with medications.
Just like many chronic physical conditions like DM, COPD, Asthma, Arthritis, Hypertension and Parkinson's Disease, many psychiatric patients would need long-term treatment to stabilise symptoms and improve the quality of life. Treatment significantly reduces relapses, readmissions, and risks to themselves or others. Most of the psychiatry conditions can be successfully managed, and patients can make a reasonable recovery on various effective treatments available including medication and talking therapy.
Just like physical conditions, including Hypertension, Diabetes, Ischaemic Heart Disease, COPD, and Asthma, many psychiatric patients may need more than one medication to control symptoms. In short, both psychiatric and physical conditions can be chronic as well as incurable, but they can both be treated to minimise symptoms, reduce risks, reduce hospitalisations and improve the quality of life.
What needs to change
We, as doctors, need to change our attitude by improving our knowledge about psychiatric conditions. Both physical and psychiatric conditions can be idiopathic (unknown cause), treatable, curable, incurable, acute and chronic. Both, physical as well as psychiatric conditions, may need short term or long term treatment. Both may need one or more than one medication or treatment to reduce symptoms. Moreover, both types of conditions can be treatment resistant. Education should start at medical school when attitudes are developing.
We need to educate patients by drawing comparisons between psychiatric and physical conditions. In my clinical practice, I have found these comparisons very helpful and efficient to educate patients, carers and healthcare professionals about the causation, treatability, curability and prognosis. Above all this education helps to infuse a hope. It also contributes to improving compliance with treatment as well as the acceptability of the diagnosis and management.
Awareness about the uncertainty being a feature of whole medicine and physical world is vital. It is important to impart a hope by talking about treatability as well as potential curability of psychiatric conditions by drawing comparisons with physical conditions. Such an approach may go a long way in combating the stigma of mental illness among patients, carers, and healthcare professionals. I believe, given the complexity of brain and mind, psychiatrists need to have the shoulders of an ox. They not only need to treat their patients but also become advocates of their vulnerable patients and educate both patients as well as their medical colleagues in other branches of medicine.
Take Home Points
Cite this article as:
Javed Latoo (2017). Causation and curability in psychiatry and other branches of medicine. The Beautiful Space-A journal of Mind, Art and Poetry. March 2017: TBSB114
By Dr Hena Jawaid, Psychiatrist
Alcoholism in teenagers is a common problem these days. It has various implications and effects on the individual and collective level. On a biological level, it can cause liver damage, hypertension, ischemic heart diseases, stroke, sensory deficits and gastric problems. Well, on the psychosocial level the manifestations like social disinhibition, confusion, impaired executive functioning, depression, psychosis (disconnection from the reality) and anxiety can take place.
On a collective scale, from a biological point of view, alcoholism is an inheritable trait. For example, if a father is a heavy drinker then the son would ultimately be at-risk. On the psychosocial scale, teenagers get into heavy drinking by modelling their elders, road-traffic accident secondary to driving under the influence (DUI), legal problems, and issues like abuse and violence can be surfaced.
What one can do to prevent youngsters from diverting towards the substance use is to identify those who can be at risk!
Recently, the study was done in California (1) that recruited 137 substance naïve adolescents (ages 12-14). Neuropsychological testing and structural and functional magnetic resonance imaging (sMRI and fMRI) were conducted. These adolescents have followed annually. By age 18, 70 youths (51%) started moderate to heavy alcohol use, and 67 remained nonusers. The aim of the study was to find out the neural predictors of alcohol use by age 18. The identified risk factors are male gender, higher socio-economic status, early dating, more externalising behaviours, and positive expectations from alcohol use.
The previous studies (2) point out lesser brain activation on tasks of working memory (recent or short-term memory), inhibition (social and movement restraints on behaviours in response to environmental situations or demands) and reward processing. The localised areas in a brain for mentioned behaviours can be used to anticipate the alcohol use amongst adolescents. The brain volume in some areas of a brain responsible for impulsivity, reward sensitivity, and decision-making noticed to be reduced (3). The reduced volume in these areas has also been used as a predictor for alcohol and other substance initiation during adolescence. The other interesting feature came out to be the early maturation of neural fibres at adolescent age (4). This can increase the sensation-seeking behaviours and ultimately result in behaviours like early dating, substance use and social disinhibition.
These findings are in line with the previous studies, which were conducted amongst moderate to heavy users to assess biological and psychosocial risk factors for their early use.
These inferences can be translated into clinical practice by identifying the high-risk group to avoid morbidity and mortality in future. The diagnostic tools like fMRI can be employed to screen at-risk group and initiate early preemptive measures.
Similar studies should be conducted in the future too to build the evidence for the Alcohol screening clinics to administer these diagnostic tools besides running screening questionnaires. The early interventions can diminish legal, medical, social and interpersonal complications of an individual and can help in building the healthy society for the generations to come.
Cite this article as:
Hena Jawaid (2017). Alcoholism in Teenage: The Beautiful Space-A journal of Mind, Art and Poetry. March 2017: TBSB115
By Dr Beenish Memon, Psychiatrist
Psychosis is a condition which affects people's mind in such a way that it alters the way they think, feel and behave. They find it hard to separate reality from non-reality. Core clinical symptoms include hallucinations (perceive to hear, see, taste, feel things which are not real), delusions (false fixed beliefs), Thought disorder (patient feels his thoughts are not his own or other people can read their thoughts).They can also present with emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect. When someone experiences any or group of these symptoms for the first time than they are diagnosed as having “First Episode Psychosis ( FEP)”.
What are EIP Services?
Early Intervention in Psychosis services works with people who are at risk of developing psychosis or have been diagnosed as having First Episode Psychosis (FEP). It is crucial that people with FEP are identified, provided with support and treatment early on in their diagnosis as it significantly improves the outcome and prognosis. The delay in treatment or people with long duration of untreated psychosis are difficult to treat and they more likely to experience poor physical health, poor social and occupational functioning and poor educational outcomes.
What led to the establishment of EIP?
Around 1980’s extensive research was done on First episode psychosis and it was identified that delay in treatment in First episode psychosis was leading to high risk of morbidity/disability (Johnstone et al., 1986; Rabiner et al.,1986). It was felt that there was a lack of services available to identify and treat the First episode in Psychosis. In the 1990s there was more evidence to support this (Wiersma et al., 1998) hence early psychosis clinical services were established, first in Melbourne and later on in many important locations in the UK, Europe and North America
Recent changes to EIP and Why?
Recent evidence suggests that Early Intervention in Psychosis reduces the severity of symptoms, risks, relapse rates, and inpatient admissions (Garety et al., 2006; Craig et al., 2004).It is also identified as being cost-effective (McCrone et al., 2011). There is a significant impact on patient’s health, personal and social needs when treatment and support are not provided earlier in the illness.
It is essential to provide better access and care with a full range of interventions recommended by NICE to enable recovery in patients who are at risk of developing psychosis and First episode psychosis. EIP services now treat patients between the age of 14-65 instead of 14-35.
The government in England introduced following New standards in April 2016 for EIP services. These standards are derived from the NICE quality standard for the care of people with psychosis and schizophrenia in adults 2015 (QS80)
EIP have got an open referral policy, and patients can be referred by anyone including Primary care services, family, educational services, and other mental health services.
Finally, new Early Intervention in Psychosis standards and targets introduced in April 2016 are par with The National Cancer targets since they both aim to promote earlier diagnosis, increased access to treatment thus improving survival rates and reducing morbidity and mortality through a variety of means.
1. Johnstone, E.C., Crow, T.J., Johnson, A.L. and MacMillan, J.F. (1986) ‘The Northwick Park study of first episodes of schizophrenia. I. Presentation of the illness and problems relating to admission’, The British Journal of Psychiatry, 148(2), pp. 115–120. doi: 10.1192/bjp.148.2.115.
2. Rabiner CJ, Wegner JT, Kane JM. Outcome study of first-episode psychosis. I: Relapse rates after 1 year (1986) American Journal of Psychiatry, 143(9), pp. 1155–1158. doi: 10.1176/ajp.143.9.1155.
3. Wiersma, D., Nienhuis, F.J., Slooff, C.J. and Giel, R. (1998) ‘Natural course of schizophrenic disorders: A 15-Year followup of a Dutch incidence cohort’, Schizophrenia Bulletin, 24(1), pp. 75–85. doi: 10.1093/oxfordjournals.schbul.a033315.
4. Garety PA, Craig TK, Dunn G, Fornells-Ambrojo M, Colbert S, Rahaman N, et al. (2006) ‘Specialised care for early psychosis: Symptoms, social functioning and patient satisfaction: Randomised controlled trial’, The British Journal of Psychiatry, 188(1), pp. 37–45. doi: 10.1192/bjp.bp.104.007286.
5. McCrone, P., Park, A. and Knapp, M. (2011) ‘Cost-effectiveness of early intervention services for psychosis’, Psychiatrische Praxis, 38(S 01). doi: 10.1055/s-0031-1277798.
6. Craig TK, Garety P, Power P, Rahaman N, Colbert S, Fornells-Ambrojo M, et al. (2004) ‘The Lambeth early onset (LEO) team: Randomised controlled trial of the effectiveness of specialised care for early psychosis’, BMJ, 329(7474), pp. 1067–0. doi: 10.1136/bmj.38246.594873.7c.
Cite this article as:
Beenish Memon (2017). What are Early Intervention in Psychosis( EIP) services? .The Beautiful Space-A journal of Mind, Art and Poetry. March 2017: TBSB113
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