And this is the problem. Modern concepts of “organic” problems affecting the brain, and the mind are very recent and based on understanding of blood, the circulation of blood, trying to understand the patterns of vital signs in illness and
It bears repeating; the classification of mental disorders has its roots in antiquity. Like most natural phenomena in early human history, mental illness was often attributed to supernatural origins (e.g., demonic possession), although psychosocial causes such as traumatic stress also were posited.
Today, the diagnosis of mental disorder initially appears relatively straightforward: But its antiquated roots still linger. Finding peripheral physical signs are considered separately from so called “mental” illness. Patients present with symptoms or visible signs of [psychological or behavioral] illness; health professionals [psychologists , psychiatrists] make diagnoses based primarily on these [psychological or behavioral] symptoms and signs; and they prescribe medication, psychotherapy, or both, accordingly. However, despite a dramatic expansion of knowledge about mental disorders during the past half century, understanding of their components and processes remains rudimentary.
Psychol Sci Public Interest 2017 Sep;18(2):72-145. doi: 10.1177/1529100617727266.Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC) Lee Anna Clark 1, Bruce Cuthbert 2, Roberto Lewis-Fernández 3, William E Narrow 4, Geoffrey M Reed 5 6
The reason psychiatrists still have only rudimentary understanding of “mental” illness is because they are still stuck in the old ways of thinking. I am not certain that the NIMH’s new (RDoC) Research Domain Criteria idea will change that.
Psychiatrists do not realize that many of these seriously ill patients have neurological, [not psychological signs and symptoms ] and need to be worked up for serious physical illness in order for their psychiatric signs and symptoms to go away or improve. Neurological investigations will not suffice either. Emergency medicine is closer to investigating these physical illnesses, and developing outpatient ambulatory critical care medicine is even closer to what needs to be developed. Really, if one looks at battlefield medicine or wilderness medical emergency care and the advances that have been made for treatment in the field, we are edging closer to what advances need to be made in psychiatric care, emergency and ongoing care.
This means thinking of the onset of acute disabling psychiatric problems as physiological emergencies which need to be investigated until the underlying physical problem is correctly treated and homeostasis restored. .
Altered mental status, neurological confusional states, the concept is pretty vague and overlaps with the disabling psychiatric concepts – blurring the line between all mental disorder which is visible. Paula and I think that from a physical standpoint, these concepts are referring to different patterns of the physical illness having -often- chronic but reversible consequences for the brain and the mind. The causes of “altered mental status” include infection, [physical] trauma, metabolic changes, and toxic ingestion. Paula and I are convinced that “infection, [physical] trauma, metabolic changes, injury, and toxic ingestion are the underlying causes of disabling mental illness as well. We think that psychiatry should devote itself to investigating what physical and metabolic illness and injuries are responsible for the ongoing chronic patterns of mental difficulties seen in the disabling mental illnesses.
This is a completely different medical process than what currently exists in psychiatry.
It flips psychiatry into a type of emergency medical specialty which looks into all possible causes of “altered mental status” and , as we have reported in past blogposts, this means being an “Ubber” doctor; meaning a “better than more than or greater than” other doctors, especially other emergency or critical care doctors…because psychiatric patients are ambulatory, even though they are very very physically sick.
This is not what psychiatrists wish to do. If they had wanted to be doctors, they would have gone into areas like family medicine, not “psychological” so called medicine.
This is the challenge of care of the mentally ill of the future. The challenge is to understand that pH of the blood circulating to all parts of the body is key to “mental health. Understanding normal variability in acid base of the blood and knowing when there are chronic difficulties making acid base balance of the blood hard, resulting in different kinds of confusional states is hard for ALL doctors. It is especially hard to understand the parameters of what is acceptable and what is dangerous if the patients are ambulatory.
And the patients, themselves, will have no idea why, suddenly, their ability to function, to work, to think, to socialize normally, to behave normally, has been compromised. Someone else must figure it out using the correct tools and the correct approach. Anyone with properly updated [must include measuring respiratory rate at rest and looking for possible active exhaling] first aid training of the future can begin to search for what is affecting the patient.
The first thing for any health professional to do is to check for a physical emergency which may be at the root of the behavior and psychological changes.
The emergency and surgical approach to looking for injury and pathophysiology fits really well.
A Primary Survey is how health professionals should approach any acute psychiatric crisis, especially when it is a sudden change to the person’s usual way of being.
to be continued……